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CLINICAL PSYCHIATRY

CLINICAL PSYCHIATRY
FOR STUDENTS AND PHYSICIANS
ABSTRACTED AND ADAPTED FROM THE SEVENTH GERMAN EDITION OF

KRAEPELIN'S "LEHRBUCH DEE PS YCHIATRIE "

BY
A.

ROSS DIEFENDORF, M.D.
IN

LECTURER

PSYCHIATRY IN YALE UNIVERSITY

MEMBER OF THE AMERICAN NEUROLOGICAL ASSOCIATION, OF THE NEW YORK NEUROLOGICAL ASSOCIATION, OF THE NEW YORK PSYCHIATRICAL SOCIETY, AND OF THE AMERICAN
MEDICO-PSYCHOLOGICAL ASSOCIATION, ETC.

NEW

EDITION, REVISED

AND AUGMENTED

gorfc

THE MACMILLAN COMPANY
LONDON: MACMILLAN &
1915
All rights reserved

CO. LTD.

COPYRIGHT, 1902, 190T,

BY
Set

THE MACMILLAN COMPANY.
Published May, 1902. Reprinted April, 1904. August, 1912; March, 1915.

up and

electrotyped.

ew edition, May,

1907

;

Norfooofi
J. 8.

Berwick & Smith Co. Cashing & Co. Norwood, Mass., U.S.A.

PREFACE TO THE FIRST EDITION
THE motive
for this

work was

to

make

the teachings

of Kraepelin in psychiatry accessible to American medical students and general practitioners, and, at the same time, to provide a full, but concise, text-book, not only for the
writer's

own

classes in psychiatry in the

Medical Depart-

ment

of Yale University, but as well for other American teachers who follow Kraepelin's views. Urged by the

rapidly increasing interest in Professor Kraepelin's teaching during the past five years in this country and the

constantly growing number of his disciples, it was the writer's first intention to publish a complete translation of the sixth edition of Kraepelin's " Lehrbuch der Psychiatric." It was feared, however, that a full translation

would be too large to best subserve the function of a textbook, and would have rendered impossible the adaptation
of

the Kraepelin psychiatry to our peculiar American

heeds.

The classification, terminology, and, wherever possible, the phraseology of this work are Kraepelinian, but the writer has taken the liberty of abbreviating disproportionately the description of some psychoses which are of less importance to the American physician, especially the

psychopathic states and thyroigenous insanity, and of laying more stress upon other more important forms, the description of acquired neurasthenia,
constitutional

traumatic neuroses, also the treatment in epileptic and
hysterical insanity

and acquired neurasthenia.

vi

PREFACE TO THE FIRST EDITION

The only omissions
and treatment

are the general etiology, diagnosis,

in the first volume of Kraepelin, but such as are of most importance have been added to the points etiology, diagnosis, and treatment of the different diseases.

The work has been done
duties

in the pressure of

routine

as Assistant Physician and Pathologist of the Connecticut Hospital for the Insane, and the writer begs

leave to express in this place his grateful appreciation of the generous advice and help of his colleagues in the

He is particuhospital, especially Dr. Charles W. Page. larly indebted to Dr. J. M. Keniston for a general revision of the text as well as for the arrangement of the chapter
on Epileptic Insanity, to Professor Raymond Dodge, Ph.D., of Wesleyan University, for criticism and suggestion with regard to the general symptomatology, and to Dr. August Hoch and Adolf Meyer for their continued inspiration and
critical assistance.

A.
MIDDLE-TOWN, CONNECTICUT, January 16, 1902.

EOSS DIEFENDORF.

PREFACE TO THE SECOND EDITION
THE
favorable reception of the
first

editions of Clinical

Psychiatry and its constantly increasing use as a text-book encouraged the writer to undertake a thorough revision

based on the seventh edition of Kraepelin's "Lehrbuch In accord with the present views of der Psychiatrie." Professor Kraepelin there are introduced many important
changes, both in the general symptomatology and in the For the condescription of the forms of mental disease.

venience of students the chapter on Methods of Examination is amplified by explicit practical suggestions adapted to the circumstances under which most of them will be

compelled to work, while the more elaborate procedure of the modern experimental laboratory has been omitted. In response to a general demand, an abridgment of the
chapter on the Classification of Mental Diseases is added to the present edition. Less hampered by restrictions as
to size, the present edition follows more closely the context of the "Lehrbuch." The description of the more important forms of insanity is less curtailed, while the

psychogenic neuroses and the psychopathic states which
received scant attention are
tion.

now

The chapter on Psychopathic

given fuller consideraPersonalities did not

appear in Kraepelin's earlier edition.
tried to

of his

The writer has make it clear by references wherever additions own have been made. The most important addihead of

tions without explicit references occur under the

Treatment.
vii

viii

PREFACE TO THE SECOND EDITION

in the preparation of the first edition, the work has been done under pressure of routine duties as Assistant

As

Physician and Pathologist of the Connecticut
for the Insane,

Hospital

leagues his Dr. Henry S. Noble, Superintendent, his grateful obligation for placing at his disposal the time and much of the material for the work.
Dr. J.

and the writer desires to express to his colappreciation of their help, and especially to

He

is

under special obligations to

M. Keniston

for help in reading proof

and the

arrangement of the chapter on Epileptic Insanity, and to Professor Raymond Dodge, Ph.D., of Wesleyan University,
for criticism

and suggestions with regard to the general symptomatology and the Psychopathic Personalities.
A.
MlDDLETOWN, CONNECTICUT,
April
6,

EOSS DIEFENDOKF.

1907.

CONTENTS
GENERAL SYMPTOMATOLOGY
PAGB

A. Disturbances of the Process of Perception VHallucinations and illusions, perception phantasms, repercep. .
. .

3

tion,

double thought, apperceptive

illusions, reflex halluci-

nations, hallucinations

and

illusions of hearing, sight, taste,

smell,

and touch.
14

Clouding of Consciousness Befogged states, disturbance of apprehension, retardation of apprehension, diminished sensibility. Disturbances of Attention Active and passive attention, blocking of attention, dulling of
.
.

.

.

.

.

.18

attention, retardation of attention, blunting of attention, passivity of attention, distractibility of attention, hyper-

prosexia.

B.

Disturbances of Mental Elaboration

......
; ;

23

Disturbances of memory, disturbances of the impressibility of memory, disturbances of the retentiveness of memory, disturbances of the accuracy of memory, fabrication of memory. Disturbances of orientation: time, place, and person disorientation; apathetic disorientation perplexity; delirious disorientation amnesic disorientation delusional disorien;

tation.

Disturbances of the Formation of Ideas and Concepts Disturbances of the Train of Thought . ., .,

.

.

29 30

.

.

External association of ideas, internal association of ideas,
paralysis of thought, retardation of thought, compulsive
ideas, simple persistent ideas, perse veration, stereotypy, cir-

cumstantiality, flight of ideas, rambling thought, desultoriness.

Disturbances of Imagination . . Simple sluggishness, retardation, indifference, excitation of the imagination, heightened suggestibility, autosuggesti. . . .

.43

bility.

Disturbances of Judgment and Reasoning

47

Knowledge and

belief, delusions,

systematized delusions, delu-

ix

CONTENTS
sions of self-depreciation, delusions of poverty, nihilistic delusions, delusions of persecution, delusions of jealousy, hypochondriacal delusions, delusions of self-aggrandize-

ment, delusions of mental soundness (absence of insight),
expansive delusions. Disturbances of the Rapidity of Thought Retardation, acceleration. Disturbances of Capacity for Mental Work

Disturbances of Self-consciousness Dual personality, double consciousness, falsifications of
consciousness.

..... .... ......
self-

56 57

58

C.

Disturbances of the Emotions Diminution and Increase of Emotional Irritability

Emotional deterioration, temporary increase of emotional irritability, change of mood.

Morbid Temperaments
irritable

Increased susceptibility to the unpleasant, apprehensiveness,
dispositions,

morbid Morbid Emotions
fanaticism,

Fear, compulsive fears, phobias, dejection, sadness with ex-

citement, morbid feeling of pleasure, wanton happiness, drunkards' humor, feeling of well-being.

Disturbances of General Feelings Ennui, fatigue, hunger, nausea, pain, feeling of shame, sexual indifference, increase of the sexual excitability, perverted
sexual feelings.

........ ... ....... .65 .......... ......
62

62

seclusiveness,

sunny

dispositions,

frivolity.

68

73

D. Disturbance of Volition and Action Diminution of Volitional Impulses
Paralysis of the will. Increase of Volitional Impulse

...... ...... .......
....
will, rigid

77 77 78 79

Motor excitement, pressure of activity, busyness. Impeded Release of the Volitional Impulse Psychomotor retardation, stupor, blocking of the
tension.

Facilitated Release of Volitional Impulses Distractibility of the will.

Heightened Susceptibility of the Will

..... .....

81

83

Weakness

of will, hypersuggestibility, catalepsy, cerea flexibilitas, echopraxia, echolalia, distractibility of the will.

Interference and Stereotypy

.......

84

Crossing of voluntary impulses, stereotypy, mannerisms, superfluous embellishment, derailment of will.

CONTENTS
Diminished Susceptibility of the Will Negativism, mutism. Compulsive Acts Impulsive Acts

xi
PAGK

88
90 90
91

Morbid Impulses

Contrary sexual instincts, sadism, masochism, fetichism, kleptomania, pyromania. Disturbances of Expression Conduct arising from a Morbid Basis

.......... .......... ........ .....
anamnesis of the
field,

93

95
97

Methods of Examination
Family
history, personal history, disease,

status prsesens, disturbances of perception, clouding of consciousness, disturbances of apprehension, disturbances of attention, disturbances of memory, orientation, train of

thought, judgment, emotional

volitional field.

FORMS OF MENTAL DISEASES
Classification of

Mental Diseases

115
115
121

Consideration of the Factors entering into a Provisional Classification
I.

Infection Psychoses

A. Fever Delirium
Etiology. Course.

121

Pathological anatomy.
Prognosis.
of

Symptomatology.
125

Treatment.

B.

Infection Deliria
Initial

Infection typhoid, of smallpox. delirium of malaria. Delirium of chorea. Deliria
deliria

of influenza, hydrophobia,

and

septic states.

Acute
131

delirium.

C.

Post-infection Psychoses

Mild Form.
II.

Second group.
.

Severe form.
J
.
'

Cerebro-

pathia psychica toxamica.

Exhaustion Psychoses A. Collapse Delirium
Etiology. Course.

.

.

.
.

.
.

.
...

136
VT*,
.

.

.

.

.

,

137

Pathological anatomy.
Diagnosis.
Prognosis.

Symptomatology. Treatment.
.

. B. Acute Confusional Insanity (Amentia) Course. Diagnosis. Symptomatology. Etiology. Prognosis. Treatment. C. Acquired Neurasthenia (Chronic Nervous Exhaustion) .
.

.

141

146

Etiology. Course.

Symptomatology.
Diagnosis.

Physical

Prognosis.

symptoms. Treatment.

xii

CONTENTS
PAGE

III.

Intoxication Psychoses 1. Acute Intoxications

........
Santonin.

159

159

Ptomaines.
2.

Chloroform.

Hasheesh.
162

Saturninia. Encephalopathia. Chronic Intoxication A. Alcoholism Acute Alcoholic Intoxication pathological and anatomical findings Chronic Alcoholism etiology, pathological anatomy, symptomatology, prognosis, diagnosis, treatment Delirium Tremens: etiology, pathological anat:

162 162

:

.

165

omy,

symptomatology,
Psychosis
:

diagnosis,

prognosis,

treatment

172
etiology,

Korssakow's

pathological
diagnosis,

anatomy, symptomatology, treatment

course,

183
etiology, symptoma-

Acute Alcoholic Hallucinosis

:

tology, course, diagnosis, prognosis, treatment Alcoholic Hallucinatory Dementia: symptomatology, course, diagnosis
.

189

.

.

.

.

195
197 200 201

Alcoholic

Paranoia: symptomatology, diagnosis, treatment

course,

Alcoholic Paresis

Alcoholic Pseudoparesis
J5.

Morphinism
Etiology.

..... ........
Anatomy.
Acute MorCocain
Hallucinosis.

202

Pathological

Chronic Intoxication. phine Intoxication. Course. Abstinence Symptoms. Diagnosis. Treatment. Prognosis. C. Cocainism Etiology. Acute Cocain Intoxication. Chronic

209

Cocain
IV.

Intoxication.

Prognosis.

Thyroigenous Psychoses A. Myxoedematous Insanity
Etiology.

........
Treatment.
Course.

214 214 216

Symptomatology.

Treatment.

B.

Cretinism
Etiology.

Pathological Anatomy.

Symptomatology.
.

Treatment.

V.

Dementia Praecox
Etiology

219 219
221

Pathology

CONTENTS
General Symptomatology: disturbances of apprehension,
disturbances of orientation, hallucinations, disturbance of consciousness, disturbance of attention, disturbance of memory, disturbance of the train of thought, dis-

xiii

turbance of judgment, disturbance of the emotional field, disturbances in the volitional field
. . .

Symptoms Hebephrenic Form: symptomatology,
Physical
course

222 229

physical symptoms,

230

Catatonic

pathological anatomy, physical symptoms, course
:

Form:

symptomatology,
241

Paranoid Forms Dementia Paranoides: symptomatology, physical symptoms, course
:

Second Group symptomatology, course Diagnosis of Dementia Prsecox Treatment of Dementia Prsecox

......... ....
.

257

260 265 272
276

VL

Dementia Paralytica
Etiology (juvenile paresis)

Pathology
Pathological

.

.

276 279

Anatomy
:

.

280

General Symptomatology

disturbances of apprehension, disturbances of memory, disturbances of the train of
.

thought, disturbances of judgment, disturbances of the . . . . . . emotions, conduct

285

Physical Symptoms sensory symptoms, paralytic attacks, disturbances of speech, ataxia, reflexes, vasomotor dis:

turbances

.

.

Demented Form
Expansive Form (megalomania)

......
.

.

290 299
301

Form (galloping Depressed Form
Agitated

paresis)

307 310

Course of Dementia Paralytica Diagnosis of Dementia Paralytica
Prognosis (arrested paresis)

.

.

.

.

314 315
318
319

VH.

Treatment Organic Dementias
Gliosis of Cortex (diffused cerebral sclerosis)
.

323
. .

323 323
326

Huntingdon's Chorea: physical symptoms, course, diagnosis, pathological anatomy Multiple Sclerosis Cerebral Syphilis: simple syphilitic dementia, syphilitic

......

pseudoparesis

326

xiv

CONTENTS
PAGB

Tabetic Psychoses
Arteriosclerotic Insanity: pathological anatomy, symptomatology, severe progressive form, diagnosis, treatment

332

333
341

Cerebral

Tumor

Brain Abscess
Cerebral Apoplexy Cerebral Trauma traumatic delirium, traumatic dementia Involution Psychoses
:

343
343 344 348

VIII.

A. Melancholia
Etiology. Pathological anatomy. Symptomatology delusions of self-accusation, hypochondriacal delusions,
:

348

hallucinations,

disturbances

of

nihilistic delusions.

B.

Diagnosis. Presenile Delusional Insanity
Etiology.

Physical symptoms. Prognosis. Treatment.

thought, Course.

.....
Diagnosis.

364

Symptomatology. nosis. Treatment. C. Senile Dementia
Etiology.

Prog-

369

Pathological anatomy. Symptomatology. Physical symptoms. Severer grade of senile deSenile Delirium. Sementia. Presbyophrenia.
nile Delusional Insanity.

IX.

Manic-depressive Insanity
Etiology

.......
Diagnosis.

Treatment.

381

381

Symptomatology: disturbances

of apprehension, disturbances of perception, disturbances of memory, disturbances of judgment, disturbances of thought, disturbances of the emotional and volitional fields

....

382

Manic States

390
:

Hypomania Mania (Tobsucht)
course
Delirious

..........
:

symptomatology, physical symptoms, course

390 394

symptomatology, physical symptoms,

Mania: symptomatology, physical symptoms,
397 400 400 402

course

Depressive States

Simple Retardation
Delusional

Form

:

Stuporous States

:

symptomatology, course symptomatology physical symptoms, course
:

.

.

.

.

.

.

Mixed

States

405 407

Irascible mania.

Depressive excitement.

Unproductive

stupor. Depression with a flight of ideas. Depressive state with flight of ideas and emotional ela-

mania.
tion.

Manic

CONTENTS
Course
of

xv
lucid

Manic-depressive

intervals, transition states

Diagnosis

Prognosis

Treatment

X.

Paranoia
nosis.

Etiology.

Querulent Insanity

XI.

Epileptic Insanity

.......... .......... ........... ........ .........
Symptomatology. Treatment.
Course.
Diagnosis.
insanity,
post-epileptic
epileptic

...... ..........
Insanity
:

duration,

412

415
417 419 423

Prog432

434

Etiology. Pathology. Symptomatology. Physical sympPeriodical ill-humor. toms. Befogged states: preepileptic

insanity,

-psychic

epilepsy,
deliria,

somnambulism,
conscious

stupor,

anxious

delirium,

dipsomania.

Diagnosis.

Prognosis.

Treatment.

XII.

The Psychogenic Neuroses
A. Hysterical Insanity
Etiology.
driasis.

....... .......
:

457

457

Pathology.

cal personality, changes in character,

Symptomatology: hysterihypochonBefogged states Physical symptoms.
states,

delirious

hysterical lethargy,

somnambuProg. .

lism, silly excitement. nosis. Treatment.

Course.

Diagnosis.

B.

Traumatic Neurosis (traumatic hysteria) Etiology. Symptomatology. Diagnosis. Treatment. C. Dread Neurosis
Symptomatology.
Course.

.

475

Prognosis.

XIII.

Constitutional Psychopathic States.
eracy.)

A. Nervousness

Symptomatology. Course. B. Constitutional Despondency Symptomatology. Course. C. Constitutional Excitement

Symptomatology. Diagnosis. Treatment. D. Compulsive Insanity Tormenting Ideas: onomatomania, arithmomania, Griibelsucht, folie du doute, erythrophobia. Phobias
:

........ .......... ......... ...... ...... .......
Diagnosis.

480

Treatment.

(Insanity of Degen-

485

485 492
495 498

Diagnosis.

Treatment.

Treatment.

agoraphobia, mysophobia, delire du toucher.

Crises. Impulsions. Course. Prognosis.

Treatment.

xvi

CONTENTS
PAGR

E. Impulsive Insanity

507

The impulse
F.

to

tramp.

Pyromania.

Impulse to kill. Course. Contrary Sexual Instincts Etiology. Symptomatology. Treatment.

Kleptomania. Diagnosis. Treatment.
510
Diagnosis.

Prognosis.

XIV.

Psychopathic Personalities A. Born criminals (moral insanity, "delinquente nato,"

515

XV.

moral imbecility). Etiology. Symptomatology. Diagnosis. Treatment B. The Unstable Symptomatology. Diagnosis. Treatment. C. The Morbid Liar and Swindler Symptomatology. Prognosis. Treatment. D. The Pseudoquerulants Diagnosis. Treatment. Defective Mental Development A. Imbecility stupid form, lighter grades, energetic type. Course. Diagnosis. Treatment B. Idiocy
:

515
521 526 531 536
536 544

....
:

}/

Etiology.

Pathology.

Symptomatology

severe

cases, light cases.

Diagnosis.

Prognosis.

Treat-

ment.

ILLUSTRATIONS
FACING PAGK

PLATE

1.

Muscular tension in catatonic stupor
Muscular tension in catatonic stupor
Cerea
flexibilitas in catatonic stupor

246

PLATE
PLATE
FIG.

2. 3.
1.

248

Catatonic writing showing verbigeration

....
.

250
251

PLATE
PLATE

4. Illustrates the normal pyramidal cell of the cerebral cortex and the cytological changes occurring in dementia paralytica

282

5. The normal cerebral cortex cerebral cortex in idiocy and dementia paralytica also the glia in the normal cortex, the presence of spider cells in dementia paralytica and their relation with
; ;

the blood-vessels

284
paretics, illustrating the lack of expression in

PLATE PLATE
FIG.

6.

A

group of

the countenance and the inelastic attitude
7.
1.

294
296

Paretic handwriting

Paretic handwriting
Paretic handwriting showing partial agraphia
.

296
.
.

FIG. FIG.

2.

296 296

3.
8.

Paretic handwriting showing complete agraphia .
Paretic handwriting
all of

.

.

PLATE
PLATE

298

9. Group of three cases of Huntingdon's chorea, were trying to look at the photographer

whom
324 334 396

PLATE PLATE

10.

Arteriosclerotic cortex

;

normal cortex

....

11.

Self-decorated
.

manic patient

PLATE
FIG.

12
1.

398
398
.

Macrocephaly
Microcephaly.
. .

FIG. 2.

398
398
.

FIG.

3.

Representing asymmetry of cranium and face Representing asymmetry of cranium and face
.
.

FIG. 4.

398

GENERAL SYMPTOMATOLOGY

GENERAL SYMPTOMATOLOGY
A.

DISTURBANCES OF THE PROCESS OF PERCEPTION

perception of external sensory stimuli depends two conditions: the adequate stimulation of the upon sensory end organ and the elaboration of this stimulation
;

THE

by the central nervous system. The loss of one or more of the senses modifies mental
development in proportion to the importance of the sensory material lost and the possibility of substituting other

sensory experience.

Loss of sight is relatively unimportant, but loss of hearing, on account of its relation to
language, is of great importance indeed, unless specially trained, deaf mutes remain mentally weak through life.
;

Illusions and Hallucinations. More important than the mere absence of sensory experience is its falsification.

Inadequate stimulation of the sense organ produces " of impressions corresponding to the "specific energy that sense for instance, an electric current may produce a sound, a taste, a tactual or a visual sensation, according
;

as

it

stimulates the corresponding sense organ.

Such sen-

sations are real illusions, but they do no harm because they are immediately recognized as illusions. In conditions of mental disturbance,

on the contrary, especially

where there

is great clouding of consciousness, the subsensations of light as the result of congestion of jective

3

4

GENERAL SYMPTOMATOLOGY

fire

the eye, or a roaring in the ear, may be interpreted as or torrents of water, giving rise to genuine deceptions

This sort of peripherally conditioned sense deception has been called elementary, on account of its origin in that part of the sensory apparatus which receives the stimulus.
States of consciousness similar to sensory perceptions may be produced by the excitation of the so-called cortical

which are not corrected.

naturally referred to an external object, and results in an illusion as to the real source of the stimulus. This group of hallucinations may be

sensory areas.

This

is

called perception phantasms.

They may occur

in

normal

individuals, particularly at the onset of sleep, as hypnogogic hallucinations. In abnormal conditions, they are

extremely vivid and misleading. They usually bear no relation to the content of thought, and, conseoften

quently, seem to the patient to belong to the external world. They have a fairly uniform content, subject only to slight modification (stable hallucinations of Kahlbaum),

and consist of senseless words, noises, figures, and the like, which are repeated over and over again. Because of their
central origin, they

may

occur after destruction both of

the peripheral sense organ and the afferent nerve. The cases of hemilateral disturbance of the field of vision, in

which the gaps produced by the disordered perception are
filled

out by the patient, point clearly to central origin in that portion of the cortex which has to do with visual

perception. There are some cases in which sense deceptions have prevailed in the normal half of the field of vision, where the cortex in both occipital lobes has been
diseased.
of the bilateral cortical blindness there has

Again, coincident with the rapid development been observed
of active perception of light.

sudden development

DISTURBANCES OF THE PROCESS OF PERCEPTION

5

Peripheral influences may also produce, directly or indirectly, conditions of excitation in the higher portions of the sensory tracts, which lead to sense deceptions, particuthe general irritability of these parts is increased. In morbid conditions, ordinary organic stimuli suffice to
larly
if

produce such falsification. In other cases, these hallucinations may appear if attention is merely directed to that sensory field, or if an emotional condition temporarily
increases the general susceptibility to stimulation. It disappears, on the other hand, as soon as the patient

becomes quiet or directs
conversation,
of environment, etc.

his attention elsewhere, as in

manual or mental employment, change

Further evidence of cooperation of conditions of stimulation in the sense organ is found in the occasional occurrence of one-sided hallucinations, the
frequent association of chronic middle ear disease with hallucinations of long standing, and the production of
hallucinations of sight in alcoholic delirium by gentle pressure on the eyeball. Usually these sense deceptions appear only in a single sensory field, and are frequent in the fields of hearing and sight.
tions

most

Sense deceptions are divided clinically into hallucina-

and

illusions.

In

the the

former there are no recoglatter

nizable

external stimuli;

real percepts.
ficult to

In some

are falsifications of cases this distinction may be dif-

carry out on account of internal stimulation of the sense organs, such as occurs in phosphenes, entotic

noises, etc.

In other cases the distinction

is clear.

The

perception of ghosts in moving clouds and limbs of trees, curses and threats in ringing bells, are evidently illusions. But the well-known visual disturbance of the alcoholic,

and the voices which torture the condemned

in his prison,

when everything

is

quiet, are pure hallucinations.

6

GENERAL SYMPTOMATOLOGY
The universal
characteristic of the entire group of sense

deceptions

is

their sensory vividness.

They depend on the

same sort of cerebral processes as does normal perception, and the false perception takes its place in consciousness among the normal sensory impressions without any disThe patients do not merely tinguishing characteristic. believe that they see, hear, and feel, but they really see, hear, and feel. In morbid conditions very vivid ideas or memory images may assume the form of hallucinations, being regarded by
the patients as real perceptions of a peculiar kind. Many investigators hold that all false perceptions should be regarded as ideas of imagination of extraordinary sensory
vividness.

But

in order that

an idea attain the

clearness

This special cause must be present. is indicated by the fact that in patients suffering from hallucinations, not all, but only certain groups of ideas
of a perception,

some

seem to play a role in the sense deceptions, and besides these there are usually ideas of the ordinary, faded, and formless The element which makes a hallucination out of type.
a vivid idea
tral

probably a reflex excitation of those censensory tracts, through which alone normal stimuli
is

come

to

consciousness
.

(the so-called

"reperception" of

If it is really these areas of the brain through Kahlbaum) whose excitation perception acquires its peculiar sensory

marks,
sions.
lies

it is

easy to see

how they may

participate in vary-

ing degrees in the active process of

renewing previous impresthere

A view of this sort would explain the fact that

ness

between the sense deception of pronounced sensory vividand the most faded memory image an unbroken series
It is possible that during the ordinary
this reflex excitation or reperception
is

of transition stages.

thought processes

always present in a very slight degree, but that only when

DISTURBANCES OF THE PROCESS OF PERCEPTION

7

the process becomes morbid, or the sensory areas themselves are in a condition of increased excitability, does the vividness
of the
tion.

memory

picture approach that of true sense percepProbably there is, moreover, a definite relation beirritability

tween the strength of the reperception and the
of the sensory areas
;

the greater their irritability, the more easily will the memory images attain sensory vividness, the lighter the reflex excitation need be to release them, and the

more independent they are of the current of thought. The extreme case would be found in the sense deceptions depending upon local excitation, which seem to the patient to be something quite foreign and external. The extreme case in the other direction would be those instances which are
not true sense deceptions at
sible to
all,

but merely ideas of great

sensory vividness. By careful investigation it is often posanalyze the data given by the patient, which apparently indicated hallucinations, and to discover that the patient does not regard the impression as objectively real,

but

merely differentiates
the reperception
is

it

from

of its forceful vividness.

his ordinary ideas on account In these cases it is probable that

special sensory tracts

strongly developed, while irritability of This seems to be is not increased.

borne out by the fact that this group of hallucinations, which has been variously designated as psychic hallucinations
(Baillarger), pseudohallucinations (Hagen),

and apprehen-

sion hallucinations (Kahlbaum), involves several or all of the sensory fields, and that it always stands in close relation to the other contents of consciousness
fications of perception,
;

while the true

falsi-

a single sensory tract,
thought.

on the other hand, usually belong to and are independent of the train of

A striking illustration of this type of hallucinations is found in a condition called "double thought." Immediately

8

GENERAL SYMPTOMATOLOGY
of

upon the appearance

any idea, the patient has another distinctly subsequent idea of the same thing i.e. every idea This double is followed by a distinct sensory after-image. thought occurs most frequently when the patients are reading, sometimes when writing, and occasionally, also, when The sensory linguistic ideas come vividly to consciousness. if the words are actually spoken. after-image disappears
;

Other hallucinations of hearing universally accompany
condition.

this

Apperceptive illusions are those in which subjective elements unite with the objective sensory data, giving rise to a distorted and falsified impression. They are of very fre-

quent occurrence in normal life prejudice, expectation, and the emotions continually influence our perceptions even in Even the most transpite of our earnest effort to be neutral.
;

quil scientific observer is never quite certain that his per-

ceptions do not unconsciously suit themselves to the views with which he approaches his investigation while in reading
;

we

unconsciously correct the errors of the type-setter from the residua of our experience. In mental disturball

for this falsification of apprehension.

ances the conditions are often extraordinarily favorable Marked emotional

excitement, great activity of the imagination, and finally, the inability to sift and correct experience by reason, all are favorable to its development. Thus, it frequently hap-

pens that the sensory impressions of patients take on fantastic forms and become the basis of a thoroughly falsified apprehension of the external world, even when there are

no true hallucinations. This phenomenon naturally occurs most frequently, both in normal and abnormal states, when the sensory impressions are confused and indefinite, and not
readily differentiated.

There

is

an

allied

group of disturbances which consists

DISTURBANCES OF THE PROCESS OF PERCEPTION
in the release of a false perception in

9

one sensory

field

through a real impression received by another, constituting the so-called "reflex hallucinations of Kahlbaum." sensory stimulus may produce conditions of excitation,

A

which, transferred to an over-excited sensory area, occasion the development of an hallucination. Similar conditions
are daily encountered in the so-called sympathetic sensations, like the unpleasant sensation of an inexperienced onlooker at a painful surgical operation. In morbid conditions these may be very marked. Especially sensations of

movement which

frequently

accompany sense impressions

seem way. There are patients who feel on their tongues the words spoken by others; a glance from some one may excite a sensation of strain.
to rise in this

A

which

very important characteristic of sense deceptions, in one way points to their origin and in another to

their importance as a disease
irresistible influence

symptom, is the powerful and which they exert over the entire thought
It is true that occasionally
;

and

activity of the patient.

a

sound and, pronounced also, that at the beginning, as well as at the end, of a mental
illusion

appears in persons mentally

disease the illusions are often recognized as such, because of their improbable content, but usually persistent illusions and

hallucinations overpower the judgment, and ultimately the patients invent the most foolish and fantastic explanations
to account for them.

The
tions

basis for this irresistible influence

is

not to be found

in the sensory vividness of the illusion, since real sensa-

and

definite evidence are useless as correctives.

Its

explanation is found rather in the intimate connection between the illusions and the patient's innermost thought, morbid
fears,

and desires. The emotional states and the feelings color the illusions in a peculiarly high degree, as one might

10

GENERAL SYMPTOMATOLOGY

expect from their influence in normal life. It is frequently observed, especially in the end stages of dementia praecox,
that illusions appear only in connection with the periodical vacillations of the emotional state, while they completely disappear in the interval. This influence of the emotional
life

upon the thought and actions only disappears with recovery, or when progressive deterioration obliterates emoIn both cases the illusions

tional activity.

may

continue,

but the patients do not react upon them. These facts manifestly disprove the general view that
real

sense deceptions regularly, or even frequently, act as the causes of delusions. To be sure, patients point to their hallucinations as the basis of their symptoms, but

there can be no doubt that the sense deceptions have a common source of origin with the other disturbances of the

In reality the patient's attitude toward his illusions and hallucinations is not the same as his attimental equilibrium.

tude toward his actual perceptions. No healthy individual would refer to himself such words as "That is the president,"

and then immediately believe he must be the president. But when these words form the keystone of a long chain of secret misgivings, an hallucination of that sort makes the most profound impression, and immediately there arises a firm conviction, not only that the words were really spoken,
but that they express the truth. In view of these facts we see no special practical value in distinguishing in single cases whether the delusion, the
emotional state, or the corresponding sense deceptions appear first. In the vast majority of cases, and especially where the sense deceptions appear with persistent delusions, all of these disease

symptoms

result of

one and the same

common

are certainly only the cause.
large

Illusions

and hallucinations present a

number

of

DISTURBANCES OF THE PROCESS OF PERCEPTION
clinical types in the different sensory fields.

11
fre-

The most

quent sense deceptions of sight are those which occur at night, the so-called visions; God, angels, dead persons, The less distorted figures, wild animals, and the like.
sense deceptions of sight which appear in daylight along with the normal impressions are much more like

common

normal perceptions and consequently more deceptive.

The

sense deceptions of the alcoholics are of this type (see The objects of the surroundings may take on an p. 176).
entirely different appearance;
vice

patients mistake strangers

for relatives and versa, and believe that the same persons are taking on different forms and faces, are making

grimaces, etc.

The most important sense deceptions
so-called voices,

of hearing are the

by The basis for their importance lies in the fundamental significance of language in our psychic life. The
is

a term which

usually well understood

the patient.

voices usually have

an intimate relation to the content

of

consciousness;
for

in fact, they are the linguistic expressions

of the patient's inmost thought,

and

for this reason
all

have

him a

far greater convincing

power than

other sense

deceptions, more even than real speech. The voices mock the patient, threaten him, and tell his secrets. They are heard in the scratching of a pen, in the barking of dogs, etc. Sometimes there are several distinct "voices" with characteristic differences.

Usually they are low, as if coming from a distance, though occasionally they are loud enough to drown all other noises. It rarely happens that the "voices" speak long sentences. Usually they consist of short, interrupted remarks. The hallucinations in fever delirium and in greatly bewildered patients are changeable and confused.

Auditory sense deceptions are seldom indifferent to the

12

GENERAL SYMPTOMATOLOGY

almost always accompanied by strong emotional disturbances and wield a powerful influence over the patients' actions. They make them distrustful, excited,
patients, but are

and even drive them
tormentors.

to angry attacks

on

their imaginary

The

so-called

"internal

voices"
etc.,

"suggestions,"

"tele-

phoning," "telegraphing,"

form a special group of

hallucinations of hearing. These naturally are not regarded by the patients as sensory in their origin. They may occur

monologue or as a conversation with distant persons; sometimes the voices of conscience seem to critias a kind of

the patient or spur him on. In all these cases the patient develops the delusion that his thoughts are known to every one, or that they are produced and influenced by outcise

side forces.

Sense deceptions in the other senses are of much less importance. False perceptions of taste, smell, dermal,
muscular, and general senses, so far as they derive their the origin from the thoughts of the patient, and not from
disturbance of the sense organs, point to a profound change of the whole psychical personality.

Where

delusions of electrical influence, of position, of

incasement of different organs of the body, the disappearance of the ears, mouth, etc., are present we no longer have simple illusions and hallucinations, but almost always a
severe disturbance of the higher psychical processes. Hallucinations develop differently. One might judge The type of the hallucination this from their great variety.

may

be determined in a measure by the form of the mental In fever delirium and infection psychoses the disease.

hallucinations

and

illusions are variable

curring in all the different fields of sensation

and dreamlike, ocand producing
Similar hallu-

a most confused and fantastic experience.

DISTURBANCES OF THE PROCESS OF PERCEPTION
cinations

13

and

illusions exist in the alcoholic delirium,

but

here they present a peculiar sensory vividness and they combine so that the separate experiences are much more definite.

Indeed, they combine so intimately with each other that they offer a good foundation for the development of " an occupation delirium." Another characteristic of these alcoholic hallucinations and illusions is that they are very

numerous and change rapidly. These sense deceptions, originating as they do from imperfectly perceived impressions, can even be created and influenced by mere suggestion. The hallucinations in cocainism which appear in the visual and auditory fields and in the field of general sensibility " are closely related. The microscopic" hallucinations of
the perception of numerous minute objects, little animals, or holes in the wall On the other hand in the epileptic delirium or little points.
sight are particularly characteristic;
i.e.

the hallucinations are accompanied by a peculiarly intense tone of feeling; for instance, the sight of blood, of fire, objects of fear, the hearing of threats, the noise of shooting,

In all of these conditions it is or the music of angels. an extensive involvement of the corprobable that there is
tex by the disease process. This seems the more probable as clouding of consciousness regularly accompanies these
states.

tory delirious states
ferent senses:

Other disease processes present even more transiwith hallucinations involving the dif-

such as manic-depressive insanity, senile dementia praecox, and occasionally paresis. In dementia, the bewildered and excited stages of dementia praecox hal-

lucinations of hearing predominate, while in similar states in manic-depressive insanity hallucinations of sight are more prominent, and particularly hallucinations of the general sensibility.

In paresis illusions are

much more

evident
infre-

than hallucinations, although both are comparatively

14

GENERAL SYMPTOMATOLOGY

quent. There is only a small group of cases in which the sense deceptions involve only a single sensation ; as, for instance, in

most cases

of acute alcoholic hallucinosis,

some

cases of alcoholic hallucinatory dementia, in there are very striking hallucinations of hearing. Also in some epileptic states, hallucinations of hearing only appear.

and which

Hallucinations of hearing alone are by far most frequent in dementia prsecox. They are rarely absent long. Usually

they represent one of the
tinue as the only
hallucinations

first

symptom

for

symptoms and often they consome time. In the delirious
It
is

states of dementia prsecox they are usually associated with

and

illusions of the other senses.

also in

dementia praecox that the peculiar disturbance called " The content of the haldouble thought" mostly occurs. lucinations is of a fearful or disturbing nature only at the beginning, while later it becomes more or less indifferent and
senseless,

which

is

in

marked contrast

to the other forms of

mental diseases mentioned above.
Clouding of Consciousness. within us characteristic mental

External stimuli occasion

phenomena which we appre-

hend immediately and distinguish as presentations, feelThis experience is designated as conings, and volitions. which is present whenever physiological stimuli sciousness,
are converted into psychic processes.
sciousness
eral
is

The nature

of con-

obscure, yet we know not only that it in gendepends upon the functioning of the cerebral cortex, but also that its individual phenomena are connected with definite, but as yet undetermined, physiological processes
in the

nervous system.

Just as the transition of the external

stimuli into sensory excitations depends upon the nature of the sensory organ, so the condition of the cerebral cortex
is

cal into conscious processes.

the determining factor in the transformation of physiologiWhether such transformation

DISTURBANCES OF THE PROCESS OF PERCEPTION
takes place in individual cases
is

15

mine, since

we have no immediate

often very difficult to deterinsight into the inner

experience of others and are compelled to draw our conclusions from their behavior.

The condition

in

which the transformation

of physio-

logical into psychical processes is completely suspended, is designated unconsciousness. Every stimulus which crosses

the threshold of consciousness, thereby arousing a psychic process, must possess a certain intensity which cannot sink

below a definite

limit.

This limit

is

called the threshold

value and varies greatly according to the condition of the While it is lowest in strained attention, the threshcortex.
old value reaches infinity in the deepest coma. It is thus possible to distinguish different degrees of the clearness of consciousness according to the character of the threshold

But even when conscious processes are no longer aroused by external stimuli, consciousness in the form of obscure presentations and general feelings may still
value.
exist.

the clearness of consciousness decreases sufficiently, befogged consciousness results (Dammerzustand) during
If
,

which neither the external nor internal stimuli can create These befogged states are clear and distinct presentations.
encountered in epileptic and hysterical insanities, as transitory states contrasting sharply with the normal life of the

Prolonged befogged states are also found in mental processes are rendered difficult and the which
individual.

psychophysical threshold is considerably raised. Sometimes the threshold value may be so altered that it is different for external

and

internal stimuli

;

that

is,

while

external stimuli have

little effect,

vivid conscious processes. The opposite condition obtains in states.

internal stimuli produce This is what occurs in delirious

demented

states,

16

GENERAL SYMPTOMATOLOGY

where not infrequently external stimuli easily produce sensations, while internal have little effect in consciousness. What occurs here is not an increase of the threshold value,
but a prolonged sinking of the psychophysical excitation. Indeed, this is the distinction between dementia and the
befogged states. Disturbance of Apprehension. The full effect of an external stimulus takes time. Experiment demonstrates that our sense perceptions reach the point of greatest clearness only after a period of

some seconds.
be retarded.

Under some
Stimuli of
all,

circumstances this process
incompletely, although no
is

may

short duration are either not apprehended at
If

or only

real difficulty of apprehension

the retardation in the development of sensory impressions is considerable, the impressions fade away before they are really perceived. Some very strong
present.

impressions may be apprehended, but they are more or less incoherent because the connecting links and the

accompanying events reach consciousness only in an incoherent and confused form. This disturbance of apprehension in its pronounced form is encountered in senile dementia (presbyophrenia) and Korrsakow's psychosis, but exists in a much less marked degree in many other
psychoses, particularly of the delirious type. The apprehension of external impression requires not only the development of a percept of sufficient strength,

absorption into the systematic interconnections of our experience. The vast majority of our impressions Presenat any given moment are obscure and confused.
its

but also

tations only become clear of past experience in the

and distinct when they find residua " memory, resonators," as it were,

through whose sympathetic vibration the sensory stimuIt is through this process, which lation is intensified.

DISTURBANCES OF THE PROCESS OF PERCEPTION

17

apperception," that each percept becomes united with our past experience, through which alone it can
calls

Wundt

"

be understood.

by memory
of perception.

This supplementing the given impression images greatly increases the delicacy of our
it

apprehension, but brings with

the danger of a falsification

The most frequent type
hension
stimuli.
is

apprethe increase of the threshold value for external
intense the stimuli

of the disturbance of

must be in order to produce an impression, the more confused and defective will be the picture of the external world. The patients
apprehend only a small part of the impressions which they receive. They fail to note and to understand their
environment.

The more

We

call

this

diminished sensibility.

The

gradual development
is

of this disturbance of apprehension

found in simple fatigue and its transitions into sleep, but also in the morbid states of extreme mental exhaustion. Ether and chloroform isolate our consciousness from

number
hol,

the external world most completely and rapidly, but a of narcotics act in a similar way ; such as, alco-

paraldehyde, and trional. Diminished sensibility
in fever,

is

also

found
it is

and intoxication

deleria, as well as in the

clouded consciousness of epilepsy and hysteria. Oftentimes also found in the various phases of manic-depressive

insanity, especially in the depressive and manic stupor, but also in the more intense maniacal excitement.

The
tal

entire sensory experience in the first stages of mendevelopment remains on the plain of simple perception.

of the external world have left no memory residue there is no network of psychological associations through which new experience may be related to the past. In the severest forms of arrested mental

As long as the impressions

development

this condition persists,

and there

is

no possi-

18
bility of the

GENERAL SYMPTOMATOLOGY

gradual clearing of the clouded consciousness. It remains forever a confused medley of vague isolated
is

presentations and feelings, in which there hension or order.

no clear appre-

Disturbances of Attention.
is

of mental
is

present in our inner field of This limitation of consciousness phenomena.
called the

At any one moment there view only a limited number
"
Since the entire
limitations

"span

of consciousness.
life

chain of our psychical of this span, our inner

must pass under the

life presents a constant coming and mental processes. One experience after another appears and disappears ; each approaches from the dark-

going of

ness of the unconscious, at first being indistinct and weak, after a short time reaching the climax of its clearness and
strength, another.

and then sinking from

sight to give place to

within the

This development of a mental phenomenon field of consciousness is coincident with that

inner activity of the will which we call attention. Our sense organs turn to the forceful impressions, and those presentations appear which strengthen the process that

claims our attention.

The

strain of attention
It is

may have
cer-

various degrees and directions. tain physical phenomena ; such as,
alterations in breathing, pulse,

accompanied by
pressure.

movements

of the body,

and blood

Attention not only strengthens a developing impression, but without doubt it retards its fading. In this way each
impression exerts an influence on
its

successors.

Their retheir devel-

lation to their predecessor inhibits or promotes

opment.

attention becomes active

In this manner the primitive passive and aimless and selective. It is not the force

of the external impressions,

but rather the attention, which

determines our inner experience. Experience is determined not so much by the strength of external impressions as by

DISTURBANCES OF THE PROCESS OF PERCEPTION

19

In a child the favoring or inhibiting effect of attention. the content of consciousness is helplessly dependent upon accidental circumstances it perceives only the most strik;

ing stimuli.

perception
cies

is

In adults, on the other hand, the process of more and more dominated by personal tenden-

which gradually develop out of the experiences of the

individual.

We train ourselves to notice certain impressions

in preference to others, so that some stimuli, however faint, have decided advantage over others. On the other hand,

we accustom

ourselves to be inattentive to regularly recurring stimuli, yielding them no influence over our psychic This development of definite "points of view," processes.
definite
interest, leads to an extraordinary the threshold of consciousness, so that at the variability of

directions of

same moment when strong
in

stimuli pass quite unnoticed,

we

apprehend with greatest acuteness the slightest alterations
affected in different psychoses. In the first place, in all conditions of advancing dementia there is a blunting of attention. Perceptions arouse no cor-

some special object. The attention is variously

responding

They are not united with the and they fail to incite him to patient's past experience pursue them further on his own initiative. In the case of a deteriorated paretic the most striking occurrences may take

memory

images.

place without creating any impression, although he may be In dementia prsecox a able to comprehend questions. striking disorder of the attention is present from almost the
Particularly in the stuporous inception of the disease. states, all attempts to arouse the attention are unsuccessful, even prodding with a needle, or touching the cornea, fails
to create

any voluntary movement.
but a suppression

This

is

not a blunting

of the attention

of the attention.

The

patients perceive well enough

what takes place about them,

20

GENERAL SYMPTOMATOLOGY

but they involuntarily prevent the perception influencing their thought or action. Even all the external expressions that accompany attention, such as the turning of the head

and eyes, and apparently also the alteration of the pulse and breathing, are absent. This disorder corresponds
with the negativistic processes found in disturbances of volition and may be called a blocking (Sperrung) of the
attention.

In some stuporous states of manic-depressive insanity a
retardation of the attention occurs.

Here

also

it is difficult

to get into touch with the patient, but only because he lacks that internal process which connects his external impressions

and

his past experience,

of the attention.
difficult,

and incites the The development of

selective activity

ideas

is

rendered
life,

not on account of deterioration in the mental

but through the process of retardation which prevents the perceptions from gaining any extensive influence over the
internal
life.

In manic-depressive insanity the external

expressions accompanying attention are usually preserved, the patients look around inquiringly, although not understandingly. They look at objects placed before them and

turn the head at a noise.

An

immediate result of these disturbances of attention,
is

both blunting and retardation,
influence

the loss of their determining

upon new

perceptions.

A

single impression

may

be able to arouse the attention and be strengthened by it, but the persistent continuance of this psychical process,
with
its

resulting choice of

the incoming perceptions,

is

lacking.

but

it

An impression once aroused may last some time, can always be displaced by a new stimulus, provided
which
This is passivity of the strong enough. observed particularly in paresis and senile It also occurs in the stuporous forms of manicis is

only the latter
attention

dementia.

DISTURBANCES OF THE PROCESS OF PERCEPTION
depressive insanity

21

and

in

many

of the

demented states

following infectious diseases.
patients resemble children who have never had experience, therefore have no ideas or memory pictures that

The

can be awakened to direct the attention. In those forms of mental weakness, in which mentality does not develop be-

yond the grade of childhood, the attention throughout life remains passive and lacks independence. Distractibility of attention is the domination of the atten-

by accidental, external, and internal influences. Limitation of the attention arises through the want of ideas that
tion

have strength enough to influence the process of apprehension is a greater flightiness of the mental The attention leaps from one impression to processes. in spite of the fact that an endeavor is made to another,
;

in distractibility there

direct the attention.

This disturbance regularly accompa-

nies those mental states that exhibit increased irritability. It is probable that in increased distractibility of the atten-

tion the separate impressions fade so rapidly that they have no dominating influence upon the incoming percep-

Details are apprehended without a comprehensive view of their relations, and the entire apprehension is
tions.
superficial.

The
is

lightest

form

of distractibility

is

found in the absentit

mindedness of fatigue.

In chronic nervous exhaustion
also the case in convalescence

more

persistent, as

is

from

severe physical or mental disease. It appears to a marked degree hi the excited stages of paresis, sometimes also in
catatonia, collapse delirium, and in the infection psychoses, but particularly in the manic forms of manic-depressive
insanity.

In these conditions a single word or the most
is

casual stimuli suffice to distract the attention.
Distractibility of attention

continuously present in some

22

GENERAL SYMPTOMATOLOGY

forms of constitutional psychopathic states, where it exerts a very powerful influence upon the mental development. The more distractible a man is, the less perception is controlled

by inner motives
is
is

arising

from experience, and the

less

coherent and uniform
Distractibility

the conception of the external world.

not to be confounded with hyperprosexia, which consists in the total absorption of the attention by a

examples of which are found in the so-called absent-mindedness of scholars and the complete absorption
single process,

of the melancholiac in his sad ideas.

B.

DISTURBANCES OF MENTAL ELABORATION

The material of experience, received through the different and clarified by attention, forms a basis for all further mental elaboration, and it is self-evident that both disturbances of apprehension, and the inability to make a systematic choice in the impressions, must affect to a marked
senses

degree the character of all intellectual processes. All higher mental activity deDisturbances of Memory.

pends largely upon memory. Every impression which has once entered consciousness leaves behind it a gradually fad" ing disposition" to its recall, which may be accomplished
either through

an accidental association

of ideas or

through

an exertion

This disposition to recollection is really identical with the residua which each new perception contributes to the store of experience and to the resources of
of the will.

memory.

The residua are strong and permanent

in direct

proportion to the clearness of the original impression, and to the multiplicity of its relations to other processes, i.e. to the interest it arouses and to the frequency of its repetition.

The vast majority

of our ideas

and the greater part

of the

association complexes with which we have to do daily, are so accessible to us that they appear of themselves under the
least provocation

and without any

effort.

dependent on impressieach of which may be disturbed retentiveness, bility independently of the other.

Memory

is

really a dual process

and on

Impressibility

is

the faculty for receiving a more or less

permanent impression made by new experience.
23

The

clear

24

GENERAL SYMPTOMATOLOGY

apprehension of events, especially when aided by active
attention, increases this impressibility, while it is lessened by difficulty of apprehension, by distractibility and indifference.
It,

therefore,

is

diminished wherever there

is

cloudi-

ness of consciousness, as in amentia, to a less extent in the absent-mindedness of fatigue, and in the states of deterioration in dementia prsecox, paresis, and in epileptic insanity,

which are characterized by stupid indifference to the environment. The most marked disturbance of impressibility occurs in Korssakow's psychosis and senile dementia, especially presbyophrenia,

although the
assimilated.

moment

impressions are

In these patients the process of perception develops very slowly, so that with those stimuli which act quickly the process of apprehension
well

apprehended and

becomes

distinctly impaired

and at the same time the pro-

cesses of consciousness fade very quickly.

In normal life it is the greatly diminished impressibility which renders it difficult to recall our dreams. This demonstrates that psychic
exist
life,

and therefore consciousness, can

without

consciousness,
activity,

with

memory. Similar conditions of clouded undoubted evidences of a psychic

but yet without memory, occur in epilepsy,

many

profound intoxications, and hypnotism. "Retrograde amnesia," in which memory is more or less
delirious conditions,

permanently destroyed without clouding of consciousness, occurs in epileptic, hysterical, and paralytic attacks, head
injury,

and some attempts at suicide, in which patients cannot remember the events which immediately precede the

attack.

Memory

for this period

may

return.

Retentiveness of

memory

for past events

depends upon the

previous impressibility, upon repetition and the native tenacity of the individual memory. Its disturbance is

manifested by an inability to accurately recall former knowl-

DISTURBANCES OF MENTAL ELABORATION
edge and important personal events.

25

Lack

of impressibility

usually accompanies lack of retentiveness, but the converse is not necessarily true, as impressibility is affected by cloudIn senility ing of consciousness, while retentiveness is not.

the former

is

far

more disturbed than the

latter;

recent

events leave no residua, while remote events recur in memory with ease and accuracy. This is even more striking in
senile

dementia and

may

psychosis the weakness of memory a definite period of the life.

occur in paresis. In Korssakow's may extend back to cover
disturbed.

The accuracy

of

memory may be
is

Even

in

normal conditions, accuracy

change of personality or the emotions,

ment

of delusions, the past is Vivid imagination and pronounced egoism imperceptibly modify the memory of past experience even in normal life
stories are embellished
self

In morbid and in the developalways more or less falsified.
only relative.

;

details, while the becomes a more and more important factor. This is

with interesting

always exaggerated in disease, while in melancholia, persecutory and expansive delusions often color the of the past until it seems like pure invention.

memory
is

mixture of invention and real experience " paramnesia. There also exist hallucinations of
(Sully),

A

called

memory"

found especially in paresis, paranoid dementia, and sometimes also in maniacal forms of manic-depressive insanity. It also
of pure fabrications, being

which consist

occasionally occurs hi epileptic and hysterical befogged states. But fabrications are particularly characteristic of

Korssakow's psychosis, and presbyophrenia, in which states the gaps produced by disordered perception are filled in with
falsifications of

memory, including even incidents of youth. These are often fantastic accounts of wonderful adventures ;
they

may

be modified by suggestion and are frequently

self-

26

GENERAL SYMPTOMATOLOGY

contradictory (see p. 186). The delusion of a double existence may be produced by confusing present experience with indistinct memory images of the past, so that every

event seems like a duplicate of a former experience. This sometimes occurs transiently in normal life; in disease
it

may

last

for

months, and

is

found particularly
is

in

epilepsy.

Disturbances of Orientation.

Orientation
its
is

the

clear

comprehension

of the

environment in

and personal

relations.

Our present

temporal, spacial, related to our past

experience in a temporal series through the function of memory. Only recent events are remembered with the
greatest distinctness ; while the rest is grouped around more or less isolated points, which form the basis for the general chronological arrangement of our experience. In Spacial orientation is partly dependent on memory.

the

first place,

memory

enables us to recognize immediately

parts of our present environment, while

even an unknown

environment

may be comprehended

when the
former.

latter includes the

through our experience motives or conditions for the

in place orientation.

But apprehension may also play an essential role In any unknown environment into

which one happens to be placed, the process
regularly clears

of perception the real situation by bringing about a up connection between the immediate impressions and our This often involves more than a mere past experience.

identification of the present with the past.

It

may

result

from a more or
reasoning.
arises

less

complicated process of reflection

and

In the same manner, orientation as to persons from the cooperation of memory, perception, and judgment. Thus it becomes apparent that lack of orientation or disorientation may arise from disorder of memory, from dis-

DISTURBANCES OF MENTAL ELABORATION

27

order of apprehension, and from disorder of judgment. In many cases two or more of these causes are combined.
Further, the disorder may involve all the fields of orientation or it may be limited to a single field, so we may dif-

between total and partial disorientation. The apprehension of the environment may be prevented by
ferentiate

the fact that the patients cannot elaborate their external impressions, or by an inhibition of thought, or by a

clouding of consciousness with or without falsification of The first case is very common in dementia perception.

pracox, where the disorientation usually results from the lack of mental activity, and may be called an apathetic
disorientation.
is no difficulty in perception. The lack the inclination to understand the patients simply meaning of what they see and hear, so that for weeks at a

There

time they

they are, In the depressive phases of manic-depressive insanity the apprehension of the environment is rendered difficult

may give themselves no concern as to where how long they have been there, or whom they see.

through the presence of retardation and there develops The patients perceive details a condition of perpkxity.

The diswell enough, but they fail to synthesize them. orientation in the most pronounced manic states may
perhaps be similarly accounted for, as there accompanies it a marked difficulty in the apprehension and elaboration
of external impressions.

The

different forms of clouding

of consciousness in focal lesions of the brain, in epilepsy,

and

in alcoholics cause a

of orientation.

pronounced disorder In the delirious states found in infection
less

more or

and intoxication psychoses,

also in hysteria

and

epilepsy,

there exist, besides the lack of clearness of apprehension, also sense deceptions, both of which cloud and falsify the
picture of the environment.

28
Iii

GENERAL SYMPTOMATOLOGY

Korssakow's psychosis there is an amnesic disorientation which depends neither upon disturbances of apprehension nor of perception.
orientation
is

While in

this condition place

usually well retained, the patients are absolutely helpless as regards time. They do not know when they came into the institution, when they were last visited

by

relatives,

when they

last dined, etc.

Events

of a

month

ago may be referred to as occurring yesterday, and again an occurrence of yesterday may be mentioned as happening months ago. This amnesic form of disorientation may occur even more strikingly in presbyophrenia, where on account of the marked
disturbance of perception in connection with the difficulty of apprehension, mental elaboration of external impressions
is

almost impossible, hence patients

fail

to get

any idea

of

their environment, although details are understood without
difficulty.

The amnesic form

of disorientation also occurs
is

in paresis,

where time orientation

most often at

fault.

Amnesic disorientation occurs in other psychoses, indeed, wherever the disorder arises from faults of memory. One's own experience in orienting himself upon awakening from
a sleep or after fainting indicates how difficult it is to regain time orientation after a severe clouding of consciousness.

The delusional form of disorientation is quite different. Here we have to do with a faulty mental elaboration of impressions which are correctly perceived and apprehended,
leading to a false opinion as to the environment in its temporal and spacial relations. The patients are not clouded,

but they maintain delusional ideas as to the time, place, and persons. Illusions or hallucinations may be the basis
mistaken personalities and the assertions of paranoid patients that they are in prison, in a bad
for such beliefs, as in

house, etc.

DISTURBANCES OF MENTAL ELABORATION

29

Disturbances of the Formation of Ideas and Concepts. Most of the complex ideas of normal life are composed of

heterogeneous elements, furnished by the various senses. In these complexes the importance of the material furnished by

any one sense depends upon the peculiarities of the individual. For some, vision is the most important sense, for others
audition; but both of these senses

may

be entirely lacking

without preventing a high development of ideation.

On the

other hand, lack of permanence of sensory impressions and imperfect assimilation always interfere with the formation
of

complex

ideas.

This

is

illustrated

in congenital

and

acquired imbecility.

The formation
fullest

of concepts is the necessary condition for the

development of ideation. In normal life those elements of experience which are often repeated impress themselves

more and more

strongly, while the accidental varia-

tions of each individual experience are driven

more

into the background.

more and The concepts thus developed

are a sort of
experience.

composite photograph or generalization of

These concepts are the most permanent and most easily reproduced of all our ideational processes. But even these

may
are

not be reproduced in totality. More and more in the developed consciousness single elements of these concepts

made

to stand for the whole.
is

The exact form

of this

often accidental, as when some The single image comes to stand for the total concept. form of this development is found in the abbreviahighest tion of thought by the use of linguistic symbols, i.e. when a

abbreviation of thought

word stands for the idea. In morbid conditions, especially
this

in congenital imbecility,

development

may

stop at

any

point.

The patients

may

cling to individual experience

without being able to

30
sift

GENERAL SYMPTOMATOLOGY
out the general characteristics of different impressions They are unable to find concise ex-

of a similar nature.

pressions for more extended experience; the essential is not distinguished from the unessential, the general from the
particular.

it

This not only prevents the development of thought, but also retards the assimilation of new material. New im-

pressions find no point of attachment in the mental life; they cannot be arranged or systematized, and pass rapidly In acquired imbecility the residua of earlier into oblivion.

experience

may

partly conceal the inability to receive

new

impressions and to form new ideas. Later, however, this defect gradually becomes more evident. Similarly in paresis, dementia praecox, and senile dementia, the circle

and general ideas and concepts are gradually replaced by the specific, the immediate, and the tangible. New impressions are no longer elaborated and the most
of ideas narrows,

recent experience is quickly forgotten, while the memory of the past is still fairly constant. In direct contrast to this is the disturbance produced by

morbid
similar

excitability of the imagination,

which correlates

dis-

and even contradictory

ideas.

Such forced and

arbitrary combinations naturally interfere with the normal development of concepts. Thus the foundation of all higher

mental activity becomes a mass of confused and indistinct psychic structures, which can give rise ojnly to one-sided

and mistaken judgments as soon

as the patients

leave

the region of immediate sensory experience. The tendency to reveries and dreams, lack of appreciation of facts, impossible plans and chimeras, so often found in imbecility,
paresis,

and paranoid dementia, are

clinical

forms of

this

disturbance.

Disturbances of the Train of Thought.

The

association of

DISTURBANCES OF MENTAL ELABORATION
ideas

31

may be

divided into two groups

:

external

and internal

associations, the former being effected by purely external or accidental relations, while the latter arise from a real

coherence in the content of the ideas.
External associations usually arise through the customary connection of ideas in time or space, of which thunder and

an example; or through habits of speech, in which a definite association of words becomes so fixed by frequent repetition that one word always calls up the others, Sound associaas in quotations and stereotyped phrases. an important and extreme form of this type, are based tions, either upon similarity of sound or of the movements of the vocal organs, as seen, for example, in a morbid tendency to rhyme. This disturbance may be so marked that the
lightning
is

associated sounds are altogether meaningless. Internal associations depend upon the logical arrangement of our ideas according to their meaning. The association

between

different individuals of the
is

same

species,

or different species of the same class, instance, the association of boy with

of this kind;

for

man and man

with

The special form animal, which emphasize some particular
etc.

of

internal

associations,

characteristics of a con-

cept, usually attributes, states of being, or activities,

means
is

of

which a preceding idea
predicative

is

called

association.

by more closely defined, That the dog is an

animal belongs to the first class of internal associations; that he is dark-colored, or that he runs, belongs to the
second.
Paralysis of thought, the simplest form of disturbance of the train of thought, is characterized by complete absence of all associations. It begins as a more or less marked retardation,

and develops

into characteristic
It occurs in

monotony and

distractibility of thought.

a moderate degree

32
in fatigue.
is

GENERAL SYMPTOMATOLOGY
Narcotic poisoning presents severer forms.
It

a fundamental symptom in the psychoses accompanied by deterioration paresis, dementia praecox, and senile de:

mentia.
Retardation of thought is manifested by difficulty in the elaboration of external impressions ; the train of thought is

markedly retarded, and the control of the store of ideas is incomplete. It may bring the train of thought to a complete In contrast to the paralysis of thought, to which standstill.
it

presents a

superficial

similarity,

this

inhibition

may

suddenly disappear under certain conditions, as fear. The they are not, like the patients do not lack mental ability
;

weak-minded or deteriorated, obtuse and indifferent, but they are unable to overcome this restraint which they themThe most pronounced form of selves very often realize. this disturbance is seen in the depressed and mixed forms of manic-depressive insanity, and perhaps, also, in the disturbance of thought in epileptic stupor.
disturbances of the content of thought are best understood as a faulty arrangement of the individual links of our

The

thought with relation to the goal ideas.
is

usually directed

by

definite goal ideas,

Normal thought and of the ideas

which appear in consciousness, those elements are specially favored which stand in closest relation to these controlling
goal ideas. Out of the large number of possible associations those only really occur which lie in the direction determined by the general goal of the thought process.

In morbid conditions the train of thought
rupted by

may

be inter-

individual ideas, or other trains of thought with

an

especially

p. 355).

may

prominent emotional tone (cf. Melancholia, of some sad experience or a fright so dominate us that our thoughts in spite of all effort

The memory

return to the same channel.

DISTURBANCES OF MENTAL ELABORATION

33

Compulsive ideas are those ideas which irresistibly force themselves into consciousness. These are usually accompanied by a disagreeable feeling of subjection to some overwhelming external compulsion. The mere fear of their

them into consciouson a basis of emotional disThey usually develop turbance, and, therefore, accompany melancholia and derecurrence
is

often sufficient to bring

ness.

pressed phases of manic-depressive insanity, also sometimes the depressive states of dementia praecox. The content of
these impulsive ideas is unpleasant and harassing. The patients are compelled to think constantly of some shocking experience, which they have had, or to depict some mis-

which may befall them. The profound emotional despondency which serves as a basis for these thoughts and at the same time furnishes a good soil for their development has associated with it a feeling of compulsion. As the disease develops, despondency becomes more predominant,
fortune,

the resistance of the patient to the ideas is gradually weakened, so that the feeling of subjection vanIn this way the original compulsive ideas are transishes.
particularly
if

formed into delusions.
If the fundamental emotional state is independent of morbid changes of the emotions, as encountered in various

psychoses, the disturbing factor in the compulsive ideas does not reside so much in their content as in the fact of their

The most striking forms of these comideas develop in the states of hereditary degeneracy pulsive Increased emotional sus(cf. Compulsive Insanity, p. 498).
constant recurrence.
ceptibility, as well as

a tendency to morbid introspection, are

the fundamental states from which these compulsive ideas In the very lightest forms there develop ideas develop.

which are unpleasant. There is still another group of cases

in

which some

34

GENERAL SYMPTOMATOLOGY

simple

common

ideas

of every train of thought, later gaining mastery;

the compulsion to recall become so prominent that the patient makes out a long list of names, and finally indexes the names of every person

development such as the name of some one, which may

interfere

with

the

whom
sort

he meets.

The compulsion
is

to count

is

of the

same

and again there

the compulsion to ask of them-

selves all sorts of questions (Gruebelsucht) (cf. p. 500). There is here a feeling of uncertainty which incites the

patient to a distinct

effort,

which

feeling

can never be

quite satisfied, because every suggestion leads to still another series. There is no end to the names, the numbers,

and the questions to be asked. The
is,

real basis for these ideas

therefore, a feeling of discomfort, identical with that
incites all of

which

us to seek for clearness and truth ;

but in the case of the patient these ideas are no longer the servants, but are masters of the psychical personality, because he has not the power to suppress them when they
hinder the train of thought. Distinguished from the compulsive ideas are the simple
persistent ideas,

ings of

unaccompanied by marked unpleasant feelcompulsion. This phenomenon is probably due to
of
definite

the absence

or

fixed

goals in

the train of

a view which is borne out by our experience thought with the persistence of some of our own ideas, whenever we give free rein to our thoughts. Rhyme, verses, and melo-

sometimes cling to us even in spite of our throw them off.
dies

efforts to

In gross brain lesions there

is

often found a

peculiar

Words persistency of linguistic expressions. used shortly before are repeated by mistake.
naming objects use words which they have
spoken.

and phrases
Patients in

just heard or
it is

Fatigue

may

so aggravate this disorder that

DISTURBANCES OF MENTAL ELABORATION

35

impossible to secure a correct answer, as one gets only a monotonous repetition of previous statements.

In another phase of the disorder, more or less motor to be sure, patients use an indicated object in the same way
previously and correctly used another. In Neisser happily names this disturbance perseveration.

they have just
cases

some

of senile

dementia with pronounced

persist-

ency of ideas, Schneider has pointed out that ideas once aroused develop very slowly. In fact, in perseveration,
one often has the impression that the patients fail to understand the new perceptions and when forced simply repeat
themselves.
Patients only

named a

picture right after one

is

If this hypothesis or two other pictures had been shown. the disorder is conditioned not so much by the correct,

peculiar stubbornness of a particular idea, but rather by the difficulty of releasing other ideas to displace it.

One should

distinguish carefully from perseveration the

tendency "to run to death the same ideas" so often occurIt is but ring in dementia praecox in a pronounced form.
another expression of stereotypy of the will. Examples of this condition may occasionally be encountered in children.
It

consists of

an impulsive, often

limitless repetition of

similar expressions, sometimes alone and sometimes interwoven in other more or less incoherent trains of thought.

The content and is not,

of these stereotyped ideas

is

quite accidental

as in simple persistent ideas, determined by that which has preceded. In morbid conditions, even when the collection and

prevented by mental disease, there remain some residual ideas of the normal This results in a state, fixed by constant repetition. monotonous content of consciousness with a marked imelaboration of

new

impressions

is

poverishment of the store of ideas.

This occurs in senility,

36
paresis,

GENERAL SYMPTOMATOLOGY
and other deterioration
processes, in which the to a few phrases, or even repeated over and over. These

train of ideas

may

shrink

down

a few words which are

phrases, in contrast to the persistent ideas of the catatonic, are not senseless, but actually express the content of the The following is an example: patient's consciousness.
Frazier went away this morning, will be back soon. Didn't ask him what time he'd come home. Frazier is working up in the lot I was up in the lot yesterday. I forget what I at something.
"

went what

for.

Frazier

is
it.

I

cared about

He asked me talking of selling the place. Father is going over there to-day. Father
;

don't care for the farm.

He didn't speak to me he is downhearted. should bring up his boys to work upon it. Frazier don't have time to work. He don't stay home much. I would advise them He
to

have a place and keep

it.

If I get well I will

keep

it, if

I can.

The boys would like to have some farm. They won't stay in a place. Frazier don't like to work on the farm. [Patient hears a woman coming up the hall.] Some woman I hear coming. If she was on
a farm, she wouldn't handle much money. If they sell the place, the children will starve for hunger. [Patient looks at her hand.]
I
If

am
he

all

sells

blacked up. I have been out on the farm a good deal. the place, the little children will starve for hunger," etc.

Circumstantiality is the interruption of the course of ideas by the introduction of a great multitude of nonessential accessory ideas,

which both obscure and delay the

train of thought. The disturbance depends upon a defective estimation of the importance of the individual ideas in relation to the goal ideas. The goal may, indeed, be

ultimately obtained, showing some real coherence, but only after many detours. The simplest form of circumstantiality

appears in the prolixity of the uneducated, who are unable to arrange their general ideas in accordance with their importance, and show a tendency to adhere
to
details.

Some even have

difficulty

in distinguishing

DISTURBANCES OF MENTAL ELABORATION
sharply what
is

37

The

actually seen from what is simply imagined. circumstantiality of the senile is probably due to the

disappearance of the general ideas and concepts. Circumstantiality is also present to a marked degree in epileptic

which the following passage taken from the bibliography of an epileptic is an example
insanity, of
:

Before one believes what others have told him or what he has read in the almanacs he must be convinced and examine himself before one can say and believe that a thing is beautiful or that a thing
is
it,

"

not beautiful ;
it

first

investigate, go through

it

yourself,

and examine

and then, when
is

through
thing

has investigated everything and has gone himself and examined it, then man can at once say the

man

is not beautiful or not good ; therefore, I myself say, if one will make a statement about a thing, or will sufficiently establish something or will speak in conformity with the truth, the thing is right or is not right, so must every man likewise examine

beautiful or

the thing as he believes himself responsible before the tribune God, and before his Majesty the King of Prussia, William the Second,

and the Emperor of Germany. " soldiers have done to me.

I will

now

relate further

what the

or incomplete development of goal ideas gives rise clinically to two important forms of disturbance of the train of thought: (1) flight of ideas, (2) desultoriness.

The absence

The
is

first effect

of a defective control over the train

of ideas

a frequent and abrupt change of direction.

The

train of thought will not proceed systematically to a definite aim, but constantly falls into new pathways which

are immediately abandoned again. The impetus for such changes of direction can arise from both external stimuli

and from

internal processes. In flight of ideas the instability of goal ideas produces a condition in which the successive links of the chain of

thought stand in fairly definite connection with each other, but the whole course of thought presents a most varied

38

GENERAL SYMPTOMATOLOGY

change of direction. The patient is unable to give long answers to questions, and cannot be held to a problem
requiring much mental work, because ideas once aroused are immediately forced into the background by others. This is a fundamental symptom of the manic form of

manic-depressive insanity, and also occurs in acute exhaustion psychoses, infection deliria, paresis, occasionally also in It may fatigue of normal life and especially in dreams.

appear in alcoholic intoxication. There is no great wealth of ideas, but on the contrary it is often accompanied by
a conspicuous poverty of thought. Moreover, the rapidity of the association of ideas is not at all increased, but
patient's incoherence, therefore, depends simply on the lack of that unitary control of the association of ideas which represses all secondary ideas and permits progress only in a definite

on the other hand

is

usually diminished.

The

any accidental idea which would normally inhibit the goal idea may assume importance. It is not, then, the rapid succession of ideas which
direction.

As the

result of this,

warrants the designation of a
bility of single ideas

flight of ideas, but the which are unable to exert any

instainflu-

ence over the course of the train of thought. In flight of ideas the direction of the train of thought is determined by external impressions, chance ideas, or
finally

by simple

associations, external or internal.
is

The

influence of chance ideas

well demonstrated in intoxica-

tion deliria, and especially in opium intoxication, in which vivid ideas of the imagination follow each other in a varie-

gated series, giving rise to an incoherent progression of unrelated fancies, to which experience offers no key. This

might be called the

delirious

form

of flight of ideas.

The rambling

thought of the

another form of the flight

hypomaniacal patient is of ideas in which the patients

DISTURBANCES OF MENTAL ELABORATION
are

39

diverted

by unimportant
is

incidents,
ject.

and
left

reminiscences, and need to be frequently led back to their subideas,

The

following

an example (the patient being asked
:

when she
"

the Hartford Retreat)
January.

bazine of Aunt Jane's.

She had on a black bomown and got another from neighbor Jenkins. She lives in a little white house Come up with an old green umbrella 'cause kitty corner of our'n. You know it can rain in January when there is a thaw. it rained. Snow wasn't more than half an inch deep, hog killing time, they

My mother came for me in
One

shoestring of her

butchered eight that winter, made their own sausages, cured hams, and tried out their lard. They had a smoke house. [But how about your leaving Hartford?] She got up to Hartford on the Dr. half-past eleven train and it was raining like all get out.
Catholic, just sat with his

Butler was having dinner, codfish, twasn't Friday, he ain't no back to the door and talked and laughed

and talked."

Here, in spite of many diversions, we see a fairly good sequence in the content of thought which centers around a

the patient's mother. In the following example, on the other hand, the predominance of motor speech ideas has led to a massing
visit of

of habitual speech associations, combinations of

common

words, and finally to simple sound associations. It might be called an external flight of ideas in contrast to an internal
flight of ideas characterized
"
I

by

internal associations.

was looking

soap. ness of feet don't win feet, but feet win the neatness of men. Run don't run west, but west runs east. I like west strawberries " best. Rebels don't shoot devils at night.

You always work Harvard

at you, the sweet boy, that does not want sweet Neatfor the hardware store.

The

train of thought is supplanted by fixed and familiar phrases, in which the influence of linguistic ideas clearly

40

GENERAL SYMPTOMATOLOGY

outweighs that of the content of thought; while sound
associations, rhymes, associations.

ance of ^this

and quotations, etc., stifle all internal The most favorable condition for the appearform is an increased motor excitability and
type of incoherent to characterize, as it is not well
this

alcoholic intoxication.
Desultoriness, the second

form of

speech,

is

more
In

difficult
it

the external form of speech is fairly well retained, but there seems to be a complete loss of goal ideas, while an incoordinate mass of ideas follow each

understood.

other aimlessly and abruptly. In the flight of ideas we were able to discover some connection, if only the most external,

between the separate links of

ideas,

which gradually

led to a

new

chain, until the original standpoint

was en-

In desultoriness there is no recogsight of. nizable association between the successive ideas, while the
tirely lost

move along for some time in simiare confused and contradictory. In phrases. They flight of ideas the course always tends toward changing
trains of thought often
lar

and hence never attained

goals,

entering new circles; train of thought does not progress at all in
in this form,
tion,

and is, therefore, always on the other hand, the

any one direcbut only wanders with numerous and bewildering
is

digressions in

which

the same general paths, the following of an example
:

MIDDLETOWN, Dec.

15, 1901.

DEAR SISTER
I received

:

your box in perfect shape and money as well. Do you wish to see me. If you care or somebody else will. Do. Awful lonesome. A new suit and fair words. This time give me a little money if you will (tell her to use slang my front yard). Give me a punch for fun. You are read that way) leave (Give her a drop
of

your poison).

Latest song attendant.

(Give her a wife she

is

DISTURBANCES OF MENTAL ELABORATION
lonesome).
Hill St.
I

41

suppose

Tom

Kellhams Pete whair Fitch.

Will Eddy. I strong don't you know he passed it to the other young from Newark but he could not start it. He did not know where it came from. He

Right

tell

me

give over

Pa Ma

Nell Har.

I got McKingleys Son over me at times he works on sleeps under. the stylish horse. He is a black strong. I am a red. You know the Pres. Brokerage and drink cigars and walks, speeches. He is

37 Port Rhoda he served 10 years at his trade he is working 14 good mack. Tell Burnie he is liked by him but not strong enough they live 9,000 miles in the air over the three miles you read in school. ... Pa Pa you know the stove he carried. 1,700 Ib. trunk strong nature, hard life when I got to let him know how on
for sense

pipe here through the converser the head electro gave and they don't speak and it was a corn sense.
by.

me
I

a dime

am

bed

now good

Yours

Aff.

Distractibility through internal
also

and external

influences

be present to a marked degree, but the newly may aroused ideas do not serve as bases for others, but simply intrude into the desultory train of thought in an incoherent

manner.
their

In this

way

it is

incoherent

jumble,

to

often possible, in the midst of obtain coherent replies to

following is an example of this (the physician's questions are enclosed in brackets)
questions.
:

The

[Why are you here ?] Because I am the empress. The dear parents were already there and everything was already there and had given me permission. I have also learned stenography. Why,
David, how are you? Even a member of the reserve, megalomania, empress. [Do you feel well ?] Oh, thanks, very well, since the government has given me permission we will be good friends.

"

Oh, God

!

my

brother Carl David the

first

write something.

[Why

are

you here?]
all.

and Olga. Ah, let me Insane. Megalomania.

[What

is

that?]
[Will

Nothing, nothing, at

[How

old are you?]

22-7-1872.

you come again ?] I do not know. When he comes I will not run after him (laughs). I must always be close I have nothing (grasps at the watch chain. (clasps her hands). But the chain is nothing. How I will at once see what time it is. "

42

GENERAL SYMPTOMATOLOGY

This example does not show, however, the repetition of single words or phrases which so frequently occur in the
catatonic productions,

and

is

shown

in the following

:

"You don't own this building, I know that. The Hartford pigpen never supported, never confirmed food, therefore are not supported and this building will pay for that and food which conWhite immortal eternal receipt for that food. The war I have the white immortal eternal receipt. Mars planet Mars. war planet, or war world Mars. The war world or the war planet Mars. White immortal eternal receipt for its existence and confirmation receipt. The Hartford pigpen is not supported or has
firmed
it.

not confirmed food or the laws of food, therefore will not be supported by those who have confirmed food. The white immortal
eternal receipt."

In extreme desultoriness the speech consists of a mere series of letters, syllables, or sounds, while in the severest

always some goal idea even though it rapidly changes, and the majority of the expressions consist of actual words; here there is a perfectly senseless repetition of the same sounds with only insignififorms of
flight of ideas there is

cant modifications, like the following:
"
Ellio, ellio, ellio altomellio-altomellio,
selo, eloo,

devo, heloo
f . f . f.

f. f. f.
f. f.

dear father,

f. f. f.

dear father,

e. e. f .

old and

new

Catholic Church,"

and so on in monotonous repetition. Sound associations seem to play an important role here, but the train of thought does not advance through it to new ideas. These disturbances which destroy or interrupt the internal coherence of thought gives rise to what is called confusion of thought, which is a prominent symptom of mental
disease.

This

symptom develops

variously.

If

the inter-

ference with the coherence of thought arises from flightiness of the goal ideas, then we have a form of confusion charac-

DISTURBANCES OF MENTAL ELABORATION
terized

43

by

flight of ideas

with

its

tendency to external and

verbal associations.

The abrupt development of many differ-

ent ideas without order, and not leading to any definite goal There may also idea, gives rise to the desultory confusion.

be differentiated
confusion, which
this

still

is

characteristic of delirious states.

another form of confusion, dreamy In

type there exists besides the disturbance of apprehension and the rapid fading away of the perceptions, a marked prominence of sensory elements in thought. There
is

also a combined

form

of confusion, in

which there

is

a

new trains of thought each other incoherently. The head fairly swims following because there is not an opportunity to marshal or survey
transitory appearance of abundant,

the rapidly appearing ideas. This type of confusion characterizes those forms of mental disease in which the rapidly appearing thoughts are elaborated into a permanent
delusion formation, in the

same way that

in

normal

life

a person gradually works into his train of thought a new idea that at first was confused. Also the presence of many

be regarded as a cause of an hallucinatory confusion, just as a normal person sometimes loses his orientation if he is suddenly placed in an inextricable
hallucinations

may

environment with new and puzzling impressions. Mental retardation can also produce a form of confusion of thought, through the slowing of the process of comprehension and mental elaboration. This has been designated stuporvus confusion. In it one sometimes encounters

a combination with a genuine flight of ideas. Finally the emotional attitude may play a very important role in the development of different forms of confusion of thought.

In some diseased mental states with marked disturbances
of the emotions, this element is of great importance.

Disturbances of Imagination.

The fund

of our earlier

44

GENERAL SYMPTOMATOLOGY

experience becomes of most value to us when we are able to bring from it into consciousness voluntary ideas and mem-

ory images.
tion.

This ability is provisionally named imaginaIt requires on the one hand reproducible residua of

former mental processes, and on the other hand that process which enables us to formulate new mental pictures out of
the simple residua of memory and make it possible to elevate ourselves above our simple sensory experience and

perform original mental work.
of imagination may be seriously disturbed in In some degree this is observed in simple mental fatigue, also in poisoning with narcotic and hypnotic drugs, but more especially in the severe grades of deterioration
disease.

The power

found in
eases.

paresis, senile dementia, and other mental disIn these latter disturbances the atrophy of the
is

imagination

The

usually combined with defective memory. ideas are not only not at one's disposal, but they may

also in large

numbers disappear.

Where

this loss is less

extensive, as, for instance, often in epileptic insanity; there

These patients still have some command of their store of ideas, but they require a very long time and considerable stimulation.

develops a simple sluggishness (Schwerfalligkeit).

The retardation which is encountered in the depressive and mixed phases of manic-depressive insanity is to all external appearances similar to sluggishness. The disturbance of thought processes of the befogged states of epileptic and hysterical insanities probably also belong here. Retardation differs from sluggishness in that it is a transitory Retardation is state, while the latter is a permanent one.
usually accompanied ground which exert

by alterations in the emotional backsome influence over the function of
life.

imagination even in normal

In
is

it

one finds that the
difficult;

elaboration of external impressions

rendered

DISTURBANCES OF MENTAL ELABORATION
indeed,
it

45

may

even be so

much impaired

as to cause

com-

plete perplexity, owing to the lack of memory pictures; the patients cannot think of anything, they lose all connec-

tion with their earlier experience, and sometimes cannot even give the names of their nearest relatives. Nothing

Thought seems to come to a standstill. Such patients may present the external appearance of profound dementia but the fact that all of these severe disturbances suddenly disappear indicates retardation, moreoccurs to them.
;

over the patients suffering with retardation themselves recognize the resistance against which they have to struggle.
indifferent as demented patients are simply unable, in spite of great effort, to are; they overcome the constraint of thought.

They are not stupid or

In the indifference so characteristic of dementia praecox there is no resistance offered to the activity of thought,
but there
is

a more or

less

complete lack of motive for

mental work.

If these patients are sufficiently stimulated,

they are able to call up some of their favorite ideas, but they are never forced to mental work of their own accord.
of what happens to them, and they have no thought of the future. Mental activity stagnates more and more, and there gradually develops a shrinking a sort of atrophy from disuse. In of the store of ideas contrast to the paretic they often surprise one by the occasional display of a much greater wealth of ideas than This very rarely it was supposed they actually possessed. in the deteriorated stages of dementia paralytica. happens This observation confirms the belief that in dementia praecox there is a real loss of mental activity. Morbid excitation of the imagination is evidenced by a special vividness of the memory images, which under cer-

They take no account

tain

circumstances acquire the strength of sensory im-

46
pressions.
states,

GENERAL SYMPTOMATOLOGY
This occurs particularly in the different delirious is almost always present a pronounced

where there

disturbance of apprehension. Another example is found in of the anxious states of melancholia, manic-depressive insanity, and of the psychopathic states, in which the

some

patients detail their fears with painstaking clearness

and

completeness. In the excited stages of manic phases of manic-depressive insanity, of paresis and of catatonia, it is a question

whether there really is an increase of the imaginative power. One might judge that there was no question as to this in the manic phases of manic-depressive insanity,
but really the realm of ideas here is barely, while it very often is even diminished.
patients assert that they
if

at

all,

Some

enlarged, of these
in the

abound

in ideas,

and even

circular depressive phases patients
assertion, in spite of retardation.

may make

the same

is, however, good reason to believe that there really exists more of an increased distractibility and flightiness of the internal

There

processes than an increased production of ideas. persistent increase in the activity of the imagination is found in a considerable group of psychopathic individuals,

A

such as the morbid adventurer and inventor, who in the
the realities of
results,

pursuit of their extravagant plans completely lose sight of life, keeping their gaze fixed only upon the
difficulties

while they never take into serious consideration the and insufficiencies of their methods. Then there

the dreamer, who gives himself up to reveries. Finally there are the morbid liar and swindler, who take the greatest satisfaction in the variegated pictures of their busy imaginais

tion.

Great activity of the imagination regularly accompanies an increased susceptibility of thought to external and inter-

DISTURBANCES OF MENTAL ELABORATION
nal causes.
in children
tibility
to

47

In normal individuals this trait is exhibited and women. Morbid suggestibility and suscepautosuggestion are regular accompaniments of

psychopathic states, especially the hysterical conditions. They are manifest here not only in the accessibility of

many

thought and feeling to striking impressions and persuasion, but also in the appearance of all kinds of physical symptoms which are released through the medium of emotional
states.

Judgment and Reasoning. Judgment and inference are the most complex products of the intellect. Since perception, memory, the formation of concepts, and
Disturbances
of

the association of ideas are their necessary preconditions,

they

will

be more or

less affected

by every imperfection

of

these processes.

But

this is not the only source of their

derangement.

Human
free

knowledge has two sources
of

:

experience,

and the
Neither

action
is

the

mind

itself

(imagination).
of

source

knowledge
tion,

independent empirical never free from preconception and expectawhile even the wildest imagination employs material
entirely
is

the other;

which originally came from experience.
sharply differentiate empirical knowledge

Nevertheless,

we

from pure

belief,

which

arises

from the recasting and interpretation of

draw this distinction. Their and traditions are as credible mythological interpretations to them as direct experience. Even in children invention and experience are sometimes only partially differentiated. Whenever invention can be easily tested by direct experience the line between the two becomes more and more
sharply defined; but even here the natural incompleteness of our apprehension or our habits of thought may lead us

experience. Primitive people do not

48
into error.

GENERAL SYMPTOMATOLOGY
If the

or unreliable, imagination

data furnished by experience is scanty is free to fill the field with its

own

creations.

[Empirical science has slowly supplanted many of the misconceptions of primitive thought, but superstition still survives among the uncultured; while even among the
cultured there are beliefs which no experience or arguments can shake. The essential characteristic of these beliefs
is

their emotional significance for the individual.

Dog-

matic opinions, ideas firmly fixed by tradition, education, and habit, acquire an overwhelming emotional value, and
not only persist in spite of experience, but even mould experience into conformity with themselves (cf. the force
of prejudice). The emotional significance of such beliefs has its basis in their relation to vital interest. feeling of helpless dependence and insecurity in the presence of the

A

unknown and mysterious in primitive races. Even

is

the

fertile soil of superstition

in most highly cultured persons and religious convictions, although more or less political dependent on the rational elaboration of experience for
their content, are characteristically inaccessible to opposi-

tion

and argument/}
Delusions

These peculiarities of normal thought help us to understand the delusions of diseased consciousness.
or
are morbidly falsified beliefs which cannot be corrected either

by

argument
or

experience.

They do not
but from
belief.

arise

from

perceptions (hallucinations or illusions), they are always due to a morbid interpretation of the events arising in the patient's own imagination. The tendency so often encountered in health,
to

deliberation, experience often associated with actual

Although

and

falsified

draw sweeping conclusions from insufficient data or to assume a causal relationship between purely accidental

DISTURBANCES OF MENTAL ELABORATION

49

occurrences, becomes an important factor in morbid conditions; the most innocent events are construed as mystic

symbols of secret occurrences, and simplest facts are full of mystery. The flight of a bird is an omen of good fortune;

an accidental gesture reveals sudden danger.
Further proof of the subjective origin of delusions is found in the close relation which they maintain to the Just as in health the self forms the ego of the patient. of reference for our thoughts and feelings, so in disease point
the mysterious creations of the imagination are most intimately connected with the patient's own welfare. The
delusions are, consequently, never indifferent to the patient except in cases of advanced deterioration. They are not

only referred to the self, but they exercise a marked influence over the patient's emotional attitude to ward his environment.
Delusions are inaccessible
to

not originate in experience.
able to correct

argument, because they do Experience, therefore, is un-

them

as long as they remain delusions.

Only

in convalescence,

when they become a mere memory

of delusions, can they be recognized as false. At the height of the disease they are as firmly established as reason herself.

So long as the morbid conditions which give
persist,

rise to

them

the delusions are unchanged. If they are relinquished or modified, the change is not due to argument, but to a change in the morbid condition. Our argument
drive the patient to admit non-essential points, but the delusion serenely reasserts itself, notwithstanding the

may

most evident
is

self-contradiction.

nal object of reference or

Even when the extersupport is destroyed, a new one

quickly found. The delusion needs no other support than the absolute conviction of the deluded.

Vivid emotional

states,

such as

and enthusiasm are important

fear, sorrow, anger, joy, factors in the origin of

50
delusions.

GENERAL SYMPTOMATOLOGY
Even
in health, anxiety and enthusiasm create the consideration of any subject, fears and

for

us,

in

hopes which really have nothing to do with the subject matter. In morbid conditions, sorrow and fear exert the
strongest influence on the falsifications of ideas. Clouding of consciousness is sometimes a factor in the

development of delusions, especially in delirious states. Delirium tremens and fever delirium, for instance, present a host of fantastic delusions with but very little emotional disturbance.

believed one day

Moreover, delusions which are firmly may be recognized as false the next,

clearly indicating a morbid condition of consciousness, which rendered their correction impossible. We have an example of this in dreams, where we are unable to detect or correct those contradictions which are perfectly clear Without doubt, therefore, we must to us on awakening. the clouding of consciousness as an essential preregard

liminary condition for the development of delusions.

In paresis, senile dementia, and dementia prsecox, delusions appear in which neither emotions nor disturbances of
consciousness play a prominent role.

The

ness, which is a prominent symptom seems to favor the development of delusions. But congenital mental weakness shows only a slight tendency to the development of delusions, and likewise many cases of senile, paralytic, and precocious dementia run their

psychic weakin these diseases,

course without delusions.
cannot, therefore,
lie

The

real cause for the delusions

in the psychic

weakness of

itself,

but only in the accompanying conditions of excitation, which permit all sorts of delusional fancies to spring up in
the patient's mind.
delusions originate
It can

be

easily

demonstrated that

most

freely during heightened or de-

pressed moods.

DISTURBANCES OF MENTAL ELABORATION
Another source of delusions

51

may

perhaps be found in

those peculiar ideas which in health are accustomed to
occasionally "pop" into our heads, and whose origin we are unable to account for. While they have no power over us, for the patient, on the other hand, they bear the

even though soon changed for others. They often intrench themselves firmly in his thoughts and dominate experience, feeling, and

stamp

of absolute certainty,

conduct.

After this

preliminary

consideration

of

all

the facts

relative to the origin of delusions,

we

are led to the as-

sumption that the essential factor is an inadequate functioning of judgment and reason. In health we are accustomed
to judge all our fancies according to the standard of our own past experience, and to regard as invention that which

does not conform to our knowledge. The patient either does not perceive the contradictions between his fancies

and his former experience, or he disregards it and hides it under assumptions which are even more fanciful. Clearly the patient has lost, not only the impulse, but the power,
to oppose, correct, or suppress his delusions. The cause of this disability was formerly sought in the peculiar attributes of the individual ideas. The doctrine of "mono-

mania," which held that the "fixed idea" was only a
circumscribed disturbance of an otherwise healthy psychic
life,

was based upon this assumption. The development of delusions is thus seen to be based on the general disturbance of the entire psychic life. They are probably incited by emotional fluctuations which transform slumbering hopes and fears into imaginary ideas. But the fact that these ideas become delusions and acquire
a power which even
the senses cannot destroy,

can only be

explained by an inadequate functioning of judgment, depend-

52
ent

GENERAL SYMPTOMATOLOGY
of con-

on impassioned emotional excitement, clouding sciousness, and weakness of the reasoning power.

The character and duration of delusions differ according to their mode of origin. Those which originate in
change with the patient's mood, and usually disappear with the emotional disturbance. Delusions of delirium, which are determined both by
emotional
disturbances

clouding of consciousness and emotional disturbances, are variegated fantastic pictures recurring in manifold forms,

with

little

or no mental elaboration or coherence.

They

likewise disappear with the clearing of consciousness and the subsidence of the emotional disturbance. Delusions de-

pending both upon mental deterioration and upon emotional disturbances do not vanish with the fading of the emotional
states.

rected

They are gradually forgotten, but are never corby reason. Such delusions occur in paresis, dementia
and
senile

prsecox,

dementia.

In these psychoses the

forgotten delusions may reappear for short periods durWith continued moderate ing emotional exacerbations.

may be firmly held and even elaborated, as in the paranoid forms of dementia
emotional excitement delusions
prsecox.

Persistent delusions are of

two types, the systematized

and the unsystematized. If systematized, the individual delusions form a part of a system i.e. they all center or more definite objects, and whenever new about some one
;

develop they are absorbed into this system. delusions are usually expressed in a logical manner. Such The unsystematized delusions may ultimately disappear, as in dementia prsecox, end stages of chronic alcoholdelusions
ism, paresis,

they may become permanent through frequent repetitions, without systematization, as in the paranoid form of dementia prsecox. The
senile psychoses, or

and

DISTURBANCES OF MENTAL ELABORATION

53

progressive and uniform systematization of the delusions without marked mental deterioration constitutes paranoia
in the strict sense of the word.

In this form the delusions

basis of a thoroughly elaborated, but falsified, apprehension of self and the environment; but even here

become the

a decided weakness of judgment
monstrable.

is

probably always de-

system of coherent delusions, sometimes found in paresis and dementia praesimilar

The somewhat

cox, are always of shorter duration.

Practically all

delusions

center in the

self,

either as

self-depreciation (depressive delusions) or as self-aggrandize-

ment (expansive delusions). Among depressive delusions, those of self-accusation stand closest to the normal life.

Many normal

persons torment themselves with the belief

that they are unlucky. In states of morbid depression the idea of guilt may be associated with the patient's

every action.

He

believes that he

is

and deceiving others;
of abominable deeds

his past appears to

constantly injuring him as a series

and

terrible crimes.

He

is

an

irre-

creature, repudiated consequently about to suffer a fitting punishment, arrest, the scaffold, the stake, or whatever else his ingenuity can invent.

deemable,

unfeeling
is

by God and

damned, and

Related to these delusions are the general fears of poverty, loss of work, or some other misfortune about to befall
themselves
this

or

relatives.

In progressing mental weakness

form of delusions

may become
is

thing, the patient included,

nihilistic, when everynon-existent or less than

nothing. large group of depressive delusions are those of persecution. They originate during periods of indisposition, discomfort, or anxiety.

A

excited

marks.

Mistrust and suspicion are by peculiar coincidences and misinterpreted reNewspaper articles and popular songs contain

54
references

GENERAL SYMPTOMATOLOGY
and even
indirect
insults.

All

assertions

of

and friendship are disbelieved. At this time, also, there usually appear hallucinations, especially auditory. The patient sees himself involved in a network of secret
love

and imminent dangers which he cannot escape. All are joined against him and gloat over his misery. Men call after him, whisper to each other, shun him, spit in front of him, etc. Food and drink have a peculiar taste, as if
hostilities

poisoned, etc. Delusions of jealousy also play a prominent rSle. The patient notices a coolness in marital relations, detects

fond glances and secret signs, finds in letters arrangements for secret meetings. The wife is embarrassed by
his

unexpected return home, tries to conceal something, coughs in a significant manner, the room is darkened.

Outside some one pounds on the door, a form scurries by the window, the last child does not resemble its father,
Indeed, these delusions as cited by the patient are sometimes presented with such good foundation that it is
etc.
difficult to distinguish

them from

ideas of infidelity that are

actually justified. Delusions of infidelity occur principally in chronic alcoholism and cocainism, but also in senile

mental disorder. In advanced mental weakness the persecutory ideas often assume a very fantastic form. Absurd somatic delusions of transformation and witchery, such as telepathy,
magical, electrical, or hypnotic influences, are common forms. Sexual delusions are especially common, varying from mysterious sexual excitation to imagined childbirth

during stupor. All these evils may be attributed to any individual or group of individuals from the neighbor or

husband, to fraternal or political societies. In hypochondriacal delusions the object

is

some

alleged

DISTURBANCES OF MENTAL ELABORATION
incurable disease.

55

Harmless physical symptoms are reas signs of syphilis, sexual excess, paresis, etc. garded With the onset of deterioration the delusions become
absurd and fantastic.

Expansive ideas

may

also

be referred to a somatic

basis.

Thus, feeble paretics extol their beautiful voice, their

gym-

nastic dexterity, although they cannot produce a single musical tone or even stand on their feet. Closely con-

nected with the hypochondriacal ideas are such expansive ideas as that the excretions are gold, Rhine wine, etc.

Sometimes delusions with a depressive content acquire the
Patients state that they significance of expansive ideas. will die at once in order to be translated to heaven ; they

send invitations to their

own

execution, which

is

to be con-

ducted with great pomp. The delusion of mental soundness, in spite of deep-seated mental disease, constitutes an absence of insight into the
disease.

morbid states

This absence of insight is almost universal in ; many patients not only consider themselves

and paranoia.

perfectly sane, but remarkably intelligent, as in paresis The external relations of the patients, the

social position

expansive delusions.

and property, are similarly transformed by Noble descent, close relation to the

temporal and spiritual authorities, even association with supernatural powers, are among the most frequent forms.

With further development the patient becomes the

Presi-

On the other hand, patients dent, the Pope, Christ, or God. boast of their untold wealth and vast estates, including
whole continents or the world
gigantic undertakings
fill

itself,

while vague plans of

their minds.

Depressive and expansive delusions are by no means mutually exclusive. They may co-exist or follow one another very closely. The victim of persecutory delusions

56

GENERAL SYMPTOMATOLOGY

discovers an adequate cause

of this persecution in exnatural right to great possession or ceptional ability, high positions. His detention is the result of jealousy or These relations are not the result of logical intrigues.

elaboration, but rather spontaneous and independent conIn sequences of the internal condition of the patient.

dementia prsecox the appearance of expansive ideas following delusions of persecution indicates a decided progress
of

mental weakness.

Disturbances of the Rapidity of Thought. The normal of the association of ideas and concepts varies so rapidity
greatly in different individuals, and sometimes even in the same individual, that it has been impossible to establish a

standard by which morbid deviations can be accurately estimated. We are, however, able to recognize two disturbances

;

namely, retardation and acceleration of the train of thought. Retardation occurs even in healthy individuals as the
result of physical

and mental fatigue. Some unpleasant It also occurs emotional states produce the same result. during the intoxication produced by alcohol, ether, chloro-

form, chloral, and to a moderate degree after the use of tobacco. This disturbance is characteristic of the depres-

and mixed forms of manic-depressive insanity, is found in the end stages of dementia praecox and paresis, and in congenital imbecility. Moderate retardation apsive

pears also in melancholia. Acceleration is less frequent than retardation.

In nor-

mal

produced only by some forms of emotional excitement, and by such drugs as morphine, caffeine, and ethereal oil of tea. In morbid states genuine acceleration
life
it is

probably never found. In flight of ideas the thought may appear accelerated, but even here real delay can usually be demonstrated.
is

DISTURBANCES OF MENTAL ELABORATION

57

The capacDisturbances of Capacity for Mental Work. ity for mental work is independent of the rapidity of
thought.
It is scarcely to

mentation, although it In normal of mental disease.

be measured by direct experiforms a most important symptom
the capacity for mental the residua of past efforts. These
life

work

is

determined by

residua condition the increase of capacity, which we call In morbid states the effects of practice are practice.

usually lessened and rapidly disappear, particularly in
congenital imbecility.

The capacity

for mental

work stands

in inverse ratio to

Increased susceptibility to fatigw susceptibility to fatigue. is very general in most forms of insanity. find it in

We

exhaustion psychoses, dementia prsecox, congenital imbecility, and paresis, where it is often the first striking

symptom of the disease. In neurasthenia it is often masked by increased nervous irritability. Recovery from fatigue is effected by relaxation and
especially

by

sleep.

Melancholiacs and neurastheniacs

recover very slowly from the effects of mental, emotional, and physical activity. This is the result, in part of diseased mental tone, in part also it results from disturb-

ances of sleep, not only in amount but depth. It has been shown that in conditions of simple overwork the sleep
is

light, attains its greatest

an incomplete abatement
ing.

depth very slowly, and of its profoundness in the

shows morn-

work is markedly decreased by It can arise from insufficient intensity of distractibility. the goal ideas, from unusual vividness of individual presentations, or finally from an increased susceptibility to
Finally the capacity for
influences. Inadequacy of the goal ideas is the cause of distractibility in paresis and dementia probably

distracting

58

GENERAL SYMPTOMATOLOGY

The vividness of individual presentations is seen praecox. in the distractibility of acute exhaustion psychoses, and
and probably also dementia prsecox and paresis. The increased susceptibility to distracting influences is a reguespecially in manic-depressive insanity,
in excited periods of
lar

symptom

of

neurasthenia, where quite insignificant

forms of irritation
all

may become

altogether intolerable.

Disturbances of Self-consciousness.

The sum

total of

those presentations which form the complex idea of
personality constitutes selfthe permanent background of our and exercises a characteristic influence on the

our physical consciousness.

and

mental
is

This

mental

life,

our mental processes. In content as well as scope, self -consciousness is determined by the experiences of each individual. It is a familiar phenomenon in dreams
course of
all

may carry on a complete dialogue indeed, one be completely taken back by some particularly strikmay Apparently in such ing expression of his interlocutor. cases the unity of self -consciousness is lost, which in the waking state permits us to oversee all our thoughts and
that one
;

inner impulses at once. Such a dual personality or splitting of self-consciousness often occurs in mental disease. Possi-

bly the

first

indications of this are found in those cases in

which sense deceptions appear to the patients as strange

Whenever a patient suffering from delirium tremens overhears some derisive dialogue

phenomena

of external origin.

about himself, or plans of a threatening nature being devised against him, there is no doubt in his mind that these are of external origin and not the hallucinatory

Unbeknown to expressions of his own thoughts and fears. himself he plays the role of two different persons. Splitting
often observed in dementia prsecox, where the patients refer to foreign influences and enemies
of self-consciousness
is

DISTURBANCES OF MENTAL ELABORATION

59

residing within their bodies, the thoughts and actions of which they differentiate very clearly from their own. Some
hysterical

symptoms may be

The temporal connections
past

similarly explained. of one's personality with the

may be

disordered in such a

way

that the

memory

of

certain periods of
pletely lost.

life of longer or shorter duration are comIf during any such period of life there has

been no development, self-consciousness remains on the

same plane that
tions of

this case the interval is bridged over

was at the beginning of the period in by means of falsificamemory or inferences. The patient depends upon
it
;

inferences in the interruptions in self-consciousness occurring in clouding of consciousness, sleep, fainting, befogged
states,

and

delirious

conditions,

and on fabrications

in

Korssakow's psychosis where

loss of

memory

is

produced

by
"

disorder of the attention.

The

so-called condition of

represents another form of disis a more or less regular alternation of different states in each of which there is
double

consciousness

"

turbed self-consciousness where there

only for the experiences of similar previous states. Thus two different personalities are dovetailed, each of

memory

disposal only a part of the total experience of the individual. As a rule, one of these personalities
its

which has at

belongs to an earlier stage of development than the other, and consequently does not possess all the skill and knowlSometimes there takes edge that the other commands.
place a reversion to a particular period of the individual's past life, which has been conspicuous because of certain experiences.

may

This condition, called ekmnesia by the French, be induced experimentally by hypnosis, and is charac-

teristic

especially of hysterical insanity. Self -consciousness is no fixed mental construct,

more

but

it

changes continuously with experience.

So disease processes

60

GENERAL SYMPTOMATOLOGY

The are able to falsify it, though not in like manner. The alteration of self-consciouscause of this is not clear.
ness in the depressive stages of manic-depressive insanity is often very striking, while in melancholia it may be
insignificant in spite of the extensive delusional conception

of the environment.

Also in delirium tremens the patients
Since the most extensive

have the most fantastic experiences without suffering any
-alteration of self-consciousness.

alterations of self-consciousness occur in paresis, dementia prsecox, and in manic-depressive insanity, the hypothesis
sis

plausible that this disease
will.

symptom

is

related to dis-

the other hand, we are accustomed to ascribe disturbances of the will in large measure to the

turbances of

On

character of the psychic personality. The particular form of the falsification of self -consciousness
is

determined by the morbid disposition.

Thus

in

manic patients the peculiar condition of self-consciousness leads to the development of expansive ideas, which in reality are nothing more than a playful expression of the emotional elation. In the depressive and stuporous phases of manicdepressive insanity the patients become not only depressed and abject, but they even feel physically altered turned
to stone, dead, and transformed into other individuals, such as the devil and animals. Similarly the paretic in

accord with his expansive and pessimistic ideas comes to believe that his body is variously altered. In dementia

pnccox this condition, although present, is less pronounced, and in contrast to paresis and manic depressive insanity is
not infrequently associated with ideas of some sort of external influence which produces the alteration. In paranoia, the disturbance of self-consciousness is very slight and confined to the
abilities.

delusional overestimation

of

the

patient's

DISTURBANCES OF MENTAL ELABORATION

61

In advanced deterioration, self-consciousness ultimately In dementia prsecox and paresis this is the disappears.
usual terminus of the mental
life.

It is to

be especially

emphasized, however, that this
ration,
cases,

is

not the result of deterio-

but a special symptom of these diseases. In some on the other hand, even when the store of ideas is
still

much
This

impoverished, the patient

retains his self-con-

sciousness
is

and can give an account

of his

particularly

common

in epileptics.

own condition. Even in pres-

byophrenia, where, on account of the marked disturbance of attention, experiences disappear entirely from memory and are replaced by the freest invention, self -consciousness
is

retained.

6.

DISTURBANCES OF THE EMOTIONS

lation to

Every sensory impression which sustains any intimate reman's welfare is accentuated in consciousness by a concurrent feeling of pleasure or pain, depending on its apparent tendency to advance or retard the general aims of
life.

Therefore, the feelings are a direct indication of the attitude of the ego to the perceptions of the external world.

According to Wundt, one can distinguish three opposite states of feeling, which rarely exist alone, but almost always accompany mental processes in various combinations;
namely, pleasure and displeasure, excitement and calmness,

perhaps preferably retardation, and finally tension and Disturbances of the emotional life often form relaxation.
the
first

striking

symptom

of disease.

But the recognition

and estimation of these disturbances is difficult, because we lack an adequate normal standard. Even in health the emotions show marked personal peculiarities, closely allied
to the abnormal.

Diminution and Increase of Emotional

Irritability.
is

The

diminution of the intensity of the emotions and most frequent disturbance. In normal
in the environment
is

their simplest

life

one's interest

reflected in

more or

less intense fluc-

tuations of his emotions.

Diminution of these emotional

accentuations indicate indifference toward the impressions This is characteristic of most forms of the external world.

mental deterioration, of which it is one of the first and most striking symptoms. Emotional indifference may be
of

marked even when external impressions are well apprehended

DISTURBANCES OF THE EMOTIONS
and elaborated.

63

This striking disproportion between disturbances of the intellect and the emotions is most pronounced in dementia praecox. In paresis, on the other hand,

mental elaboration

is

disturbed to a

much

greater degree

than the emotions.
All phases of the emotional life seldom suffer equally. Naturally the patient loses most easily those feelings which are not directly connected with the changes of his own ego,

but are related to the more remote, external world, and further those feelings which have lost their sensory proper-

and are aroused only through the higher mental processes as concomitants of general ideas and moral principles. The active interest of the patient becomes exclusively selfish.
ties

He

loses all pleasure in

mental work, and

all feeling for

the

higher claims of propriety, morality, and religion.

Considera-

tion for his environment, his family, relatives, and finally for mankind in general, has no influence on his conduct. He
loses the sense of

shame and lacks
is

all

comprehension of the

conventions of social intercourse.

Emotional deterioration

symptom

of

very often the first striking dementia praecox, and advances with the
It regularly occurs in senile deis

progress of the disease.

mentia, and sometimes
its

an early symptom

of paresis.

In

appears, also, in simple senility. Emotional deterioration is also prominent in many forms of simplest form
it

" moral imcongenital imbecility, especially the so-called in which the patients show a certain shrewdness becility/
7

in the

attainment of

selfish

advantages which often conceals

the real severity of the disease. Lower or sensuous feelings possess a greater momentary intensity, but are at the same time more transitory than
the higher moral aesthetic sentiments, which accompany and determine our thoughts and actions throughout our entire

64
life,

GENERAL SYMPTOMATOLOGY
and act as checks on sudden emotional impulses
of the

lower order.

The absence

of these checks in imbecility gives rise to

sudden, but transitory, outbursts of passion. Without a firm foundation for the emotional life a mere trifle, a word, the tone of the voice, suffices to plunge the patient from the

most
spair.

blissful self-complacency into

the most profound de-

This

is

an

The emotional
of

especially prominent symptom in paresis. indifference characteristic of the end stages
is

dementia prsecox
is

tional ebullitions. indifference

A permanent

regularly accompanied by such emocharacteristic of emotional

lack of insight.

The retardation

of depressed
superficial

manic-depressive patients sometimes presents a

similarity to the emotional indifference of the deteriorated, but the former realize their condition, and often complain

that they are forsaken and desolate.
of the emotions is characteristic of

An

especial vivacity
children.

women and

The emotional
influenced

states are highly unstable and are readily by momentary conditions. The great ease with which vivid feelings appear and disappear is characteristic
of

some

of the psychopathic states.

This condition under-

lies

the syndrome of hysteria.

In this disease ideas have

such an intense emotional tone that a powerful influence is exerted not only over the will but also over such physical
processes as are, in general, not under voluntary control; as, breathing, circulation, pulse, muscles of the bladder, rectum, and hair, secretions of the glands, as well as the

accuracy of movements and the clearness and intensity of
sensations.

temporary increase of the emotional irritability is seen in some of the excited stages of paresis, catatonia, and in
Since the manic-depressive insanity. vividness of the temporary emotional state forces the
of

A

manic phases

DISTURBANCES OF THE EMOTIONS

65

restraining influence of the higher feeling completely into

the background, this condition

is

accompanied by the im-

change of mood. A similar condiportant phenomenon tion is observed in the intoxicated individual, in whom
the exuberance of
feeling

abrupt change of
for

mood.

is so often accompanied by In this condition it is possible

one to influence markedly the tone of feeling of the patient except in catatonic excitement, where negativism
prevails.

Morbid Temperaments. The same experience may arouse wholly different mental attitudes in different individuals,
according to the constitutional tendency to certain tones of Because of the feeling, the temperament of the individual.
infinite variety of

impossible to describe

the combinations of feelings it is almost all the different types of temperafield this difficulty is

ment.

In the morbid
of the forms.

even greater;

hence we must content ourselves with a brief sketch of only

some

Since displeasure exerts in general a stronger influence over our mental life than pleasure, we would expect to find This it playing the more prominent role in morbid states.
to discover in
increased susceptibility to the unpleasant leads to a tendency all of life's experiences only that which is

unpleasant. The past is crowded with sad experiences and the future a source of anxiety. The individual's own wellbeing is the centre of his thought, and every insignificant

ailment

regarded as a sign of threatening disease. The dejection which in normal life accompanies sad experiences gradually wanes, but in disease even a cheerful environis

ment

fails
it.

to mitigate

sadness, indeed,

it

may even

in-

tensify

Whenever morbid sadness is accompanied by an inner tension, the emotional state becomes one of apprehensiveness.

66

GENERAL SYMPTOMATOLOGY
feels

The patient

a lack of security and freedom, together with a lack of confidence in his own ability. He awaits

with apprehension the outcome of every act, and doubts its In this state his own physical justification and fitness.
a very fruitful source for the development of There develops a self-torture and an all sorts of doubts. of liability. This type of feeling furnishes exaggerated feeling
condition
is

is

the basis for the morbid fears to be described later, and also often seen in the incipient stages of melancholia.

When

this increased susceptibility to the unpleasant is

associated with excitement, there exists what is known as an irritable disposition. This is characterized not only by a

general tone of displeasure toward everything, but

by an

emotional excitement which demands expression and is held in check only by a constant struggle. This lack of

means a persistent variation of the emotional equilibrium and a condition of instability with occasional violent
control

outbursts of feeling, which sometimes take the form of
despair

and sometimes
in

of anger.

Despair

is

encountered
is

chiefly in congenital

neurasthenia, while

anger

found

especially

the

epileptic

and

hysterical

constitutions

(Irabundia Morbosa).

Morbid sensitiveness to the outer world does not always
lead to passionate outbreaks, but sometimes produces that type of temperament termed seclusiveness. Seclusiveness is

not accompanied by that passionate feeling of anger that goes with the defiance of a normal individual, but it indi-

more or

cates a sort of shrinking from the impressions of life with a less clear consciousness of one's own insufficiency.

Conversation with strangers, entering a new environment, unusual demands, and difficulties appear to a patient as unsurmountable obstacles. This condition underlies the

conduct of

many

of the merely

"
peculiar

"

individuals.

A

DISTURBANCES OF THE EMOTIONS

67

history of such peculiarities often antedates the outset of

dementia prsecox.

The pronounced feelings of pleasure are found in those happy sunny dispositions that are always in good humor, see things on the best side, and are most enthusiastic.
often a pressure of activity, which incites the individual to various changing unsuccessful pursuits; a combination, which also exists in
is

Associated with this state there

manic-depressive insanity. Another modification of the emotional

life is

fanaticism.

Here

develops prominently types of feeling, of a religious and sexual nature, which control especially thought and action. These individuals may exhibit the
also

there

most extraordinary feeling of happiness that rises above all external sadness and adversity. The hysterical constitution arises from this sort of a basis. Closely related to these
fanatics are the morbid swindlers with their great love for

adventure, and for the exciting and the unusual. The exaggerated joy in their own inventiveness forces all deliberation into the background. exist here.

Hysterical

symptoms

also

A

closely allied disposition is morbid frivolity,

charac-

by superficiality of the emotions. Here there is an increased susceptibility to superficial distractions while serious things are not taken seriously. Life in general is regarded as a joke. Associated with this morbid frivolity, which is an essential element in some forms of imbecility and weakmindedness, there is regularly a defective development of the higher feelings, a selfishness and instability of
terized

the

will.

A common characteristic of this condition of frivolity is an
exaggerated
self -consciousness.

The

patients'

own

abilities

and work appear to them

in

an

especially favorable light.

68

GENERAL SYMPTOMATOLOGY

These patients not only grossly overestimate themselves, but have a corresponding lack of sympathy for others. This
selfish

onesidedness of the tone of feeling exists in

many

born criminals, also in the pseudo-querulants, where it is It is probably also a combined with great irritability.
favorable soil for the development of genuine querulants and perhaps the allied forms of paranoia.

Morbid emotions are distinguished Morbid Emotions. from healtliy emotions chiefly through the lack of a sufficient cause, as well as

by

their intensity

and

persistence

;

furthermore the tone of feeling usually corresponds to some of the well-known mixed feelings. Even in normal life

moods come and go

in

an unaccountable way, but we are

always able to control and dispel them, while morbid moods defy all attempts at control. Again, morbid emotions sometimes attach themselves to some certain external occasions, but they do not vanish with the cause like normal feelings,

and they acquire a certain independence. By far the commonest form of the unpleasant morbid emotions is /ear, which may perhaps be regarded as a combination of a feeling of displeasure with an inner tension. It influences the whole physical and mental condition more profoundly than any of the other emotions. The inner
exhibited physically by the facial expression, bodily attitude, convulsive action of the muscles, in a moan or an outcry, in an act of defence or escape, in attacks on
tension
is

the surroundings or the patient's own life. Besides this there is apt to be precordial oppression, palpitation, pallor, increased respiration, tremor, and sometimes perspiration

and an increased
conditions fear

desire to urinate

and

defecate.

In morbid

patients feel often well aware that their fears are groundless.

usually without an object at first. The afraid without knowing why, and indeed are
is

In the

DISTURBANCES OF THE EMOTIONS

69

constitutional psychopathic states the indefinite fear often

assumes peculiar forms, as the feeling of homesickness and the like. In acute mental disturbances the indefinite anxious forebodings
fears.

become

fixed into

more or

less

definite

fear, like all extreme emotions, is always a clouding of consciousness. accompanied by Fear is not maintained at the same intensity for any

Extreme

considerable length of time, but shows remissions, and aggravations, the latter especially at night. Fear is most

pathognomonic of melancholia of involution, where it is seldom absent. It occurs frequently in depressive forms of manic-depressive insanity, but may be absent. It occurs
also in the befogged states of epilepsy, in delirium tremens, and in the beginning of catatonic excitement. Paresis

sometimes presents fear in

its

most extreme form.

A large group of disturbances characterized by fear is found in the so-called compulsive fears, phobias. These fears
are sometimes associated with some personal experience or idea which has given rise at some time to fear. In the lightest forms such fears are encountered in normal individuals, but here they lack the persistency

and obtrusive-

ness which characterize the phobias. The compulsive fears are characteristic of

some forms

of

may appear transitorily in These compulsive fears include manic-depressive insanity. the fear at the sight of or contact with certain objects, as
spiders, knives, needles, etc.;

the psychopathic states, but

on deserted

also the fear of being alone the fear of crowded rooms, of open or streets, closed doors, etc. (see pp. 499-503). These patients are

tormented by the idea that their clothes do not fit properly, that they themselves are soiled or poisoned by contact with
others, that they might have swallowed needles or fragments of glass, that in tearing up any scrap of paper they might

70

GENERAL SYMPTOMATOLOGY
etc.

Other closely allied disturbances are the feelings of discomfort which arise whenever individuals are compelled to come into any sort of relations with others, as in erythrophobia, morbid blushing.

have destroyed valuable papers,

While fear has been designated as sadness with inner tension, simple dejection is defined as sadness with inhibition ; in other words, anguish with a feeling of insufficiency. The basis for this emotional state is found in the sorrow
arising in the person himself,
all of

which impresses

itself

upon

the experiences of life. As the result of this, the entire past seems but a series of misfortunes and failures;

the present
all sorts of

is

troubled and dark, and the future dubious;
arise,

sad thoughts and forebodings
is

which

may

lead to delusional ideas of

but the most painful
feel neither

self-reproach and persecution, the feeling of desolation. Patients

pleasure nor sorrow; indeed, they do not respond emotionally to any of the impressions of the outer One patient expressed himself by saying that he world. " To be sure I see things well like a cinematograph. felt I don't feel them." The normal pleasure in enough, but

mere existence gives place to a feeling of weariness of life. The alteration of the tone of feeling which is characteristic of some of the circular depressive phases of manic-depressive
insanity as a rule

accompanied by a retardation of thought and action. The patients regard their condition as the most agonizing; they feel as if they were inwardly dead, had
is

become

heartless

and morally
physical

desolate.

They frequently

entertain ideas

of

alteration.

patients are not without feeling, their occasional attempts at suicide.

In reality these as may be judged from

The retardation may

suddenly give place to excitement. Sadness with excitement is occasionally observed in manicdepressive
insanity,

occurring either as an independent

DISTURBANCES OF THE EMOTIONS

71

of the disease.

phase or as a transitional stage between different phases In this case the mood is sometimes sad,

sometimes anxious or passionate, the patients expressing themselves in wailing and moaning, in states of anxiety, or in outbreaks of irritability. The latter form is particularly

common.

The

patients are fretful, discontented, at variance

with themselves and their environment, and annoyed by trifles. They grumble and growl in the most intolerable

manner and show outbursts
provocation.
conceit

of passion of this

An emotional state

on the slightest sort combined with

sarcastic is exaggerated sometimes encountered in syphilitic insanity. Many of the emotional states of the hysterical patient exhibit a mixture

and an attempt to be

of sadness

and excitement with passionate

irritability.

epileptic presents a special type of emotional disturbance namely, a simple dejection with a feeling of weariness of life. Occasionally it is associated with a feeling of
;

The

is a sort of homesick feeling with an indefinite yearning and inner restlessness, which

inhibition,

but usually there

leads to suicidal attempts, indulgence in alcohol, or aimless wandering. Yet irritability with sudden violent outbursts

In the epileptic bequite common. fogged states a tense anxious feeling predominates, someof great intensity
is

times combined with great irritability. Furthermore in all of these emotional states there may be a mixture of a sexual
or ecstatic feeling of pleasure.

The morbid feelings of pleasure are less frequent than those of displeasure. They occur especially in alcoholic intoxications and alcoholic psychoses, manic-depressive insanity, paresis, dementia praecox, morphin and cocain intoxication.

The

feeling of increased strength, enthusiasm,

enterprise

which

the facilitation

and from alcohol probably originates in of the release of motor impulses in the brain,
results

72

GENERAL SYMPTOMATOLOGY

while further action of the drug causes irritability, restlessIn the manic forms of manicness, and aimless activity.
depressive insanity in which there of pleasurable feelings, irritability,
is

a similar combination

the emotional disturbance
origin.

is

and pressure of activity, believed to have a similar

This belief

perimentation. the disorder.

substantiated by physiological exIn both conditions there is no insight into
is

The emotional

attitude in both bears the
is

stamp

of a

wanton happiness, and self-confidence

greatly

increased.

The high

spirits so characteristic of the chronic alcoholic

represent another type of morbid feeling of pleasure, and are designated drunkard's humor. The same state may
exist in delirium

tremens where, however,
fear.

a sort of concealed
arise

Its origin

is

mingled with unknown, but may
it is

from the drunkard's insusceptibility to however, humiliation and his moral apathy to vice. In paresis the pleasurable feelings are apt to be marked, especially the In this disease, however, these feelfeeling of well-being.
ings often exist unaccompanied by motor excitement, and in spite of the expansive ideas, there is absent the lack of
restraint

and fresh energy that is so characteristic of the manic exhilaration. In the later stages of paresis the feelwithout a trace of the
ing of well-being subsides to a silly thoughtless happiness irritability which is found in the

In dementia prsecox, during the excited stages, pleasurable feelings take on the form of a silly, purposeless hilarity and exuberance with outbursts
later stages of the alcoholic.

of silly laughter, which, in contrast to the hilarity of the manic forms of manic-depressive insanity, seem to bear no
relation to the patient's ideas

and environment. Cocain, morphin, tobacco, and the bromides also produce In tobacco smoking characteristic feelings of well-being.

DISTURBANCES OF THE EMOTIONS

73

the feeling of agreeable contemplation is due purely to a soporific effect; the bromides produce a feeling of well-

being by relieving a state of inner tension. The feeling of ecstasy, which occurs especially in epilepsy, and sometimes
in hysteria, seems to be very similar to the dreamy state which follows opium smoking. The origin of morbid feelings of pleasure is very difficult to determine, both because they may arise from a great many different disturbances,

sometimes somatic and vaso-motor, sometimes primarily emotional, and sometimes intellectual. Different types of
feeling

may

exist at the

same time or may succeed each

other rapidly, as seen in the mixture of fear and humor in the alcoholic and of ecstasy and anger in the dreamy states
of the epileptic.

Disturbances of General Feelings.

General feelings are

those emotional states which stand in close and inviolable
relation to self-preservation, such as feelings of fatigue and hunger. They are to be regarded as admonitions, which

gradually develop out of the experience of countless generations into involuntary and instinctive impulses. In ordinary life these feelings inform us of our bodily needs, and they

imperiously exact actions adapted to the circumstances. The performances of these actions can usually be inhibited

by conscious
self-denial;

although often only by means of great the feelings themselves are, on the contrary,
volition,

only thoroughly silenced in some way or other.

when

the indicated need
life

is

relieved

In normal

a general feeling

may disappear when we pay no heed to it. We are able to overcome weariness when work demands our strength; hunger abates when we are unable for a long time to satisfy it. When at last we have the opportunity to attend to our needs for rest and food, we miss at first the painful weariness and hunger which makes the restoration of our strength

74
so easy.

GENERAL SYMPTOMATOLOGY
Only when we have rested
for

some time do we

again experience a feeling of weariness, while hunger gradually returns as soon as we begin to eat. In normal life the performance of mental and physical

The basis is accompanied by a feeling of pleasure. for this experience lies in the fact that the formation and
work
maintenance of personality depends upon activity. If this feeling of pleasure is absent, one regularly develops a form
This is the form of ennui that develops from and soon forces one to some sort of endeavor. To a normal man enforced idleness is most irritating. Among the insane this form of ennui is usually absent because
of ennui.
idleness

the patients, even although unemployed, are completely absorbed in their own morbid mental processes. The appear-

ance of this ennui in a patient may, therefore, be regarded as a favorable sign; yet one must be cautious not to confuse it either with the feeling of discontent that is often referred
to
of

by the dejected patients as ennui, or with the pressure The complete absence of activity of the manic patients.

ennui in dementia prsecox is a very important symptom. Here there is a complete loss of volitional impulse from

which the desire for activity takes its origin. The patients can in spite of clear consciousness lie abed weeks and months without in any way becoming uneasy at the lack
Their lack of ennui always indicates a profound disorder of the mental life, and especially accomof activity.

panies progressive deterioration.

A wholly different significance attaches to that unpleasant
which accompanies excessive exercise as a sign of warning. This form of weariness generally indicates in a normal individual an actual need for rest; in other words, fatigue. Patients sometimes fail to show their fatigue, although there is real
feeling often designated as weariness

DISTURBANCES OF THE EMOTIONS

75

need for rest. In many excited states, especially in manic forms of manic-depressive insanity, there is often a complete absence of fatigue in spite of the fact that the patients
are exhausted

by continual

restlessness.

The

feeling of hunger is similarly disturbed in these

same
often

psychoses.

In paretic and catatonic patients there

is

a senseless voracity, although the well-nourished patients have no need of such an amount of nourishment. In the
constitutional psychopathic states and in hysteria, without any perceptible relation to the state of bodily nutrition, there may be a prolonged absence of the feeling of hunger,

which

is suddenly replaced by gluttony. Severe disturbances of the feeling of nausea are almost

always signs of a far-advanced deterioration. Such patients consume the most disgusting things,, even their own dejections.

Not infrequently they swallow

nails, stones, pieces

of glass, or animals, not only with suicidal intent, but con-

stantly overpowering their nausea from pure greediness. These patients also lose those feelings which cause us aversion at the mere contact with filth or dirt and impel one to keep clean, not only the body, but the whole environment. They recklessly soil themselves, even intentionally, with their own food, their own saliva, urine, and even feces.

The feelings of physical pain are often abolished. In conditions of excitement, especially with intense fear, even severe injuries produce no sensation at all, although conSuch patients pluck out their tongues or eyes, cut open the abdomen, etc., deeds which would be utterly impossible for a man with a normal
sciousness

may

be perfectly

clear.

.

sense of pain.

This insensibility to physical pain is often found in demented patients, especially in paretics, in whom, to be sure, the destruction of the nervous conducting paths

76
is

GENERAL SYMPTOMATOLOGY
an
essential antecedent.

to pain encountered in
is

epileptic patients in these conditions the threshold essentially different; of pain only appears to be raised.

The absence the hysterical and

of the sensibility

There

is finally

a group of feelings which pertain to the

maintenance

of the race rather

than to self-preservation;

namely, the sexual feelings. patients the feeling of shame

Among bewildered and excited may pass wholly into the back-

ground; yet one sometimes observes distinct evidences of the feeling of shame in the great excitement of manicdepressive cases sexual feelings.

when it is not overpowered by The rapid disappearance of the

increased
feeling of

shame even without sexual excitement is a striking symptom of dementia prsecox. Such patients denude themselves recklessly,

and masturbate
also tend
gestures.

speak shamelessly about sexual matters, persistently and openly. These patients
(copralalia)

to

employ obscene language

and

Sexual feelings in mental disease are either increased, Sexual indifference occurs in many abolished, or perverted.

forms of the constitutional psychopathic
ticularly in hysteria, also in morphinism.

states,

and par-

An
is

sexual excitability which
,

is

more frequent,

increase of found in some

idiots, but in a more pronounced degree in dementia praecox, and also in the excited stages of paresis, the manic forms

of manic-depressive insanity,
verted sexual feelings are

and

in senile dementia.

Per-

those in which sexual feelings occur exclusively in connection with persons of the same sex, associations with certain objects, or accompanied by
brutality (see p. 92).

D.

DISTURBANCE OF VOLITION AND ACTION
disturbances of the psychic
life

ALL

find their final ex-

pression in volition and action. The idea of a definite aim (some change either in ourselves or our environment) forms

the starting-point of a volitional act. This idea is accompanied by feelings which are converted into impulses for

the attainment of that aim.
is is

The

direction of

any action

determined, therefore, by an idea, while its performance determined by the intensity and the duration of the

accompanying feelings. Morbid disturbances of volition manifest themselves in the most varied ways: the energy of the volitional impulse can be diminished or increased; its release facilitated or impeded; or the direction can be modified by external or internal influences; morbid impulses can forcibly suppress the normal will; or natural impulses can assume morbid forms; finally, the conduct of the insane is naturally influenced by all those disturbances which occur in other spheres of their mental life, although the volitional process itself presents no disturbance.
Diminution of Volitional Impulses.
pension of volitional activity is
It is

The complete

sus-

termed paralysis

of the will.

produced by extreme fatigue, profound alcoholic

in-

toxication,

and
It

in the narcoses of chloroform, chloral,

and

morphin.

characterized by an absence of energy. Ordinary impulses find no issue in action, while even the most powerful incentives of personal well-being and moral
is

claims

fail

to

influence

the patient.
77

A

more or

less

78

GENERAL SYMPTOMATOLOGY

complete paralysis of the will occurs in the end stages of progressive mental deterioration senile dementia, dementia
:

prsecox,

and

paresis.

This

is

characterized by a

marked

diminution of personal
the lower,

initiative,

except in gratification of

selfish, greed, If left to themselves, the gluttony, and sexual desire. patients are content to sit around, inactive, displaying very

and vegetative impulses, such as

animation and staring vacantly into space. In dementia prsecox it can often be shown that the patients have
little

not lost the voluntary control of their actions, but normal In the end stages of incentives fail to influence them.
deterioration
reflex.

the

only movements are

involuntary

and

Similarly, defective volition appears in congenital

imbecility as the result of defective development. Increase of Volitional Impulse. The universal indication
of the increase of volitional impulse is motor excitement. But we are really justified in speaking of an increase of volitional

impulse only when there is a marked disproportion between the intensity of the excitation and the importance of the

In alcoholic delirium, for example, we find marked unrest which cannot be explained by the patient's delumotives.
sions, hallucinations, or emotions,

but must be referred to a

morbid motor excitation. Patients will not remain in bed, show a pronounced restlessness, and constantly busy themselves as if employed in some occupation. In alcoholic intoxication, increase of volitional impulses begins with simple loquacity, and increases to brawling, screaming, and aimless
activity.

In chronic cocain intoxication (see

p. 210) there

develops a peculiar motor excitability which seems to form a transition to the morbid pressure of activity which is a
characteristic
p. 387),

symptom

of manic-depressive insanity (see

and

is

sometimes found in exhaustion psychoses and

paresis.

DISTURBANCE OF VOLITION AND ACTION

79

of activity takes the

In the lighter hypomaniacal disturbances this pressure form of general instability and busy-

ness, great talkativeness,

ticulation.

Such

to animated gespatients collect all sorts of useless things,

and a tendency

begin countless undertakings which they never finish, and, when unrestrained, travel aimlessly about. In more marked

excitement the goal ideas become more and more inconstant, and one can hardly detect any purpose at all in their
ever changing, incoherent activity. Patients scream, laugh, sing, dance, disrobe, tear their clothing, smear themselves,

wash in their own urine, destroy everything they can and pound incessantly with their hands and feet.

reach,

Catatonic excitement furnishes a picture essentially different from that of the manic pressure of activity. In

the manic excitement,

all

impulses lead to more or
first

less

purposeful actions, though they might at

appear pur-

In catatonia, on the contrary, we poseless and senseless. have to do with movements which at most have no definite
aim.
is

Although the characteristic excitement in catatonics

more moderate, the movements are entirely purSuch patients make grimaces, contort the body, poseless. run about, clap their hands, and utter a succession of senseless noises. These movements are not pure volitional acts, as there is no antecedent idea of their purpose. Patients themselves often assure us that they do not know why
often

they perform such absurd antics. The strength Impeded Release of the Volitional Impulse. and rapidity with which a volitional impulse is converted
into action
also
is dependent, not only on its own on the resistance which it has to overcome.

intensity,

but

Thus, fright

and

present obstacles to the realization of our which can be overcome only by the most strenuous intention, exertion of the will.

fear

may

80

GENERAL SYMPTOMATOLOGY
The psychomotor
retardation,

which

is

the most important

disturbance in the depressed states of manic-depressive insanity, is probably due to a similar increase of resistance.

Such patients require special exertion of the will for almost every movement. All the actions are characteristically slow and weak, except when a powerful emotional shock
breaks through the resistance. The retardation may become less pronounced under the influence of continued effort.

In severe cases independent volitional action is almost imIn spite of every apparent exertion, the patients possible.
cannot utter a word or at best answer only in monosyllables, and are unable to eat, stand up, or dress. As a rule they clearly recognize the enormous pressure lying upon them,
" stupor is usually applied to these disturbances, but they are only superficially related to the stupor of catatonia.

which they are unable to overcome.

The name

"

not rendered

In catatonic stupor the release of movements in itself is difficult, as action is occasionally both rapid

and powerful. But every impulse is almost immediately followed by the release of an opposing impulse which prevents the consummation of the act. Thus, we often see the
desired

movement begin

all right,

but

it is

immediately

in-

terrupted and extinguished by the opposing impulse. Here the impulse is not hindered by internal resistance, but is simply quenched by a counter impulse. In contrast to the retardation, in which there is a continuous hindrance, one As soon as the blockmight refer to this as a blocking. ade is raised, the counter order disappears, and the action

proceeds without the slightest difficulty. As a result of this blocking of the will

many

reactions

which normally occur without special act of volition are
suppressed at their inception. The patients will not look up when accosted, or shake hands when the hand is proffered.

DISTURBANCE OF VOLITION AND ACTION
If

81

one threatens them with a knife, or pricks the eyelid, they may perchance shrink away, but they never make any welldirected effort to protect themselves;
in the

most uncomfortable

positions,

and

they continue to lie will sit for hours

of steps they could the persistent holding open of Possibly the eyelids, the regular swallowing of saliva, and the retention of urine and feces may be explained in this way. The
in the sun,

when by taking a couple

reach the shade.

whole attitude of the patient becomes strained and unnatural.

In blocking of the will there is no lack of impulses, but rather a balance of counter impulses. Hence we do not find the lassitude characteristic of retardation but a rigid

which discloses the play of opposing influences. Movements take place with an excess of tension which extension,

tends almost equally over all associated groups of muscles: the resulting action depends on relatively slight preponder-

ance of one group of muscles over the opposite group. Hence both station and movement appear tense and stiff.
Occasionally the relative strength of impulse and counterimpulse varies, sometimes one and sometimes the other

gaining the upper hand. A movement suddenly stops and then just as suddenly begins again. It proceeds by jerks

and

is

awkward and clumsy.
all this

ness of

Possibly it is the consciousthat leads to the innervation of opposition

more remote muscle groups. The entire limb is apt to come into play for the simplest movements, which thereby become ponderous and indefinite. Facilitated Release of Volitional Impulses. Both the impressions of the outer world and our inner experience develop in us continually more or less tension of the will, which tends to relieve itself in the most varied expressions.
Part of these operations are independent of voluntary con-

82
trol.

GENERAL SYMPTOMATOLOGY
The
is

greater part of them, however, are subject to inhibition through voluntary effort. The ease with which

impulse

converted into action depends upon the development of the inhibitions which we control. Our mental

development means in general an increase of inhibitions.

The

child reacts immediately, while

growing self-control

enables the

to suppress numberless impulses, before they develop into action. The female sex with its heightened emotional irritability tends to remain on the plain of

man

the child.

The
on

restraining power of the inhibitions naturally depends the strength of the impulses and the intensity of the

emotional state, from which they originate.

On

the other

hand, there are well-recognized influences that facilitate the release of impulses and thereby lessen the resistance to
the conversion of an impulse into action. This operates to a greater or less degree in all forms of psychomotor activity.

Whenever movements are continued there arises a degree of excitement which means a diminution of
tion.
it

certain
inhibi-

has already been pointed out that morbid Indeed, inhibition is gradually reduced by activity. Still more evi-

dent

is

the increase of excitement in manic

and catatonic

patients when their restlessness is not restrained. An unrestrained discharge of impulses always makes it more difficult for the patients to control themselves.

A
by

most

significant diminution of inhibition is

alcohol.

Ether and cocain have a similar

effect

produced both

in the acute

and chronic

intoxications.

The

facilitated release of volitional impulse is a constant

symptom
leaves

in

some forms

of

morbid constitution, especially

in hysteria.
little

In this disease the intensity of the emotions room for the reasoned action, hence these patients

sometimes suddenly find themselves performing strange and

DISTURBANCE OF VOLITION AND ACTION

83

incomprehensible acts, as thieving, cheating, and self -mutilation, apparently at variance with their intention.

The motives of Heightened Susceptibility of the Will. action have two sources: external stimuli; and those
relatively constant principles of action

which

arise

from

within rather than from without, and render the individual's conduct more or less independent of his surroundings. The
control of actions
in children

by these general principles is lacking only and unstable individuals. In diseases this conweakness of the
in
conflict
will,

trol is lost in

increased psychomotor

excitability,

and

with

overwhelming morbid

impulses.

Weakness

of will is

found in

all

forms of imbecility, where

the fixed principles of action are lacking. There is no inThe chief characternal unity or consistency in conduct.
teristic is

a hypersuggestibility, through which the patients become the prey to every accidental influence. This condition

purest form in paresis. Similar phenomena are induced through suspension of these fixed principles of action by means of hypnotism.
is

found in

its

,

Transient hypersuggestibility is found in catalepsy, where often the limbs of the patient will remain in any position in which they are placed until, as the result of extreme

muscular exhaustion, they tremblingly obey the laws of In this condition there is often found a moderate, gravity. but constant, muscular resistance called cerea flexibilitaSj
in

which

it is

possible to

mould the limbs

into

any desired

Less often patients are found who will repeat for position. some time any simple movement, once started, or who will
laboriously imitate everything done in their presence
echo-

praxia.

patient involuntarily repeats every word he hears, although at the same time giving evidence of considerable elaboration of impressions by his

In

echolalia

the

84

GENERAL SYMPTOMATOLOGY

Indications of these symptoms, especially cerea flexibilitas, are occasionally observed in the most varied diseases, such as hysteria, epilepsy,
ability to solve simple problems.

manic forms

of

manic-depressive insanity,

paresis,

and

alcoholism; but the whole group of symptoms is most pronounced in dementia prsecox, especially the catatonic

form.
Distractibility of the will is

a morbidly easy translation of

ideas into action.

It usually

ceptibility of the will,

accompanies heightened susbut is differentiated from it by a
It is
is

reaction to internal as well as to external stimuli. to conduct what the distractibility of the attention
intellection,

to

and

effectually prevents

all

permanent

volitional

control of action.

Sudden

resolutions are half carried out

only to yield to new ones. The patients are wholly under the influence of the environment, whether good or bad. Distractibility of the will is found in certain conditions of
It accompanies hystemanic and delirious excitement. ria and some forms of imbecility as a permanent personal
characteristic.

Interference and Stereotypy. The carrying out of any act is in general determined by the goal idea. Since simple our movements are usually governed by the principle of

economy, we seek to reach the goal with minimum expenditure of strength and time. In case this principle is clearly
transgressed, or if the act is clearly inappropriate, we have a disturbance of conduct which is provisionally called interference, in

which the correspondence between intention and accomplishment is interfered with by the interpolation of
incongruous impulses. Here, apparently, incidental impulses break into the natural flow of conduct. A similar

condition obtains in the blocking of the will. One may regard the blocking of the will as a special case in which the

DISTURBANCE OF VOLITION AND ACTION

85

incidental impulses are directly opposed to the original impulses; then interference would be regarded as a crossing
of the original impulses

by the incidental impulses in various The blocking of the will would then be only directions. a special form of the general disturbance which may be Both described as a crossing of the voluntary impulses.

symptoms belong to catatonia. The incidental impulses may influence action in many The simplest form is probably seen in the different ways.
reiterated repetition of chance impulses. Normally every as soon as the aim is realized, is forced into the impulse,

background by other impulses. But where the pursuit of any definite aim is disturbed and there still remains a general pressure of activity, any impulse once released has a good chance to be repeated as long as the active residua Such an of the impulse are not obliterated by new aims.
impulse becomes, so to speak, an incidental impulse which breaks through the more or less aimless operations of the
will

and becomes more
is

insistent with each repetition.

This

disturbance

called stereotypy

(Kahlbaum).

Whenever stereotypy is marked (a) by a blocking of the will we find a continuous tension of definite muscle groups; whenever it is marked (6) by crossing of voluntary impulses we find a reiterated repetition of the same movement, (a) In muscular tension the patients remain in the same place and attitude for an almost incredible length of time in spite of the greatest discomfort. They stand in the same
corner, kneel in a definite place,
lie

in

bed with

legs curled

up and head extended, so
a

rigid that they can be lifted like

Others grip a piece of bedspread with their teeth, log. or convulsively grasp a piece of bread or torn-off button. The expression of the countenance is also rigid, mask-like,
the forehead

drawn up as

if

in surprise, the eyebrows ele-

86

GENERAL SYMPTOMATOLOGY
The eyeballs are often are protruded like a snout. lips

vated and the eyes often wide open.
turned side wise and the
(b) Stereotyped

movements have an unlimited variety. The

patients turn somersaults, rap rhythmically, walk about in peculiar places, hop, jump up and down, roll and creep on

the ground, pick at the clothing or hair, and grit the teeth.

These movements can be repeated innumerable times, for weeks or even months. In all these movements the patients
are absolutely reckless of themselves and their environment. Mannerisms are a kind of stereotyped movement, consisting of ordinary

movements

peculiarly modified.
gait,

The
go in

patients walk with a peculiar

drag one

foot,

straight lines or in circles, hold their spoons at the very end, eat in a definite rhythm, and shake hands with stiffly

Mannerisms are especially common in speech. Grunts, lisping, peculiar words, phrases, and inflection, and numerous repetitions of the same words are among the most frequent forms. Stereotypy is a characteristic of the catatonic forms of dementia prsecox, but also occurs in exhaustion psychoses and in paresis, where it is
extended fingers.
is occasionally observed a form of stereotypy which is scarcely the same as that just described. It consists of peculiar rhythmical movements, especially rocking the body while sitting and

only a transient symptom. In the end stages of catatonia there

standing, nodding or shaking the head, clapping of the hands, etc. This symptom always indicates a complete
deterioration of the will.
It
is

likewise observed in the

most profound idiocy. It is a fair hypothesis that these movements are the expression of certain primitive arrangements of our nervous system, which in the absence of the
higher processes determine the activities. In stereotypy voluntary activity never proceeds to a goal.

DISTURBANCE OF VOLITION AND ACTION
Even when the

87

patients are active their activities move in a circle. On the other hand, there is a type of crossing of impulses in which the incidental impulses produce only a superfluous embellishment of the intended act. The act is
finally

accomplished, but only after

all sorts

deviations.

The

patients skitter along,

and go backward, walk
of additions

on their knees, bend away backward, or drag one foot: they extend their hands in wide circles, or with sudden swoops or stiff jerks. In shaking hands they touch one's hand only with the little finger, or with the back of the hand. In eating they grasp the spoon by the tip, arrange
the food in
ful;
little piles,
is

or count seven between each

mouth-

the water

The bed

drunk in little sips or after long pauses. clothing and their garments are arranged in a

peculiar way. The catatonic grimacing garded as belonging here.

may

also be re-

From
by

this

transitions to those disturbances
Schtiles derailment of the will,

embellishment of conduct there are regular which have been termed

where acts are completed from the way in which they are begun. very differently For instance, in grasping the spoon to eat the patients may twirl it about in a circle, then lay it down again, or in carrying a glass of water to the mouth upset it on the table,
suddenly turn it upside down, and return it to the table. Also in their speech it is often observed that the patients
will

suddenly stop and begin anew with another thought, which in turn is just as abruptly left for another, so that
the goal idea
is finally lost sight of. It is in this way that desultoriness arises (see p. 40). In this crossing of impulses many of the acts stand in no definite relation to any

goal idea. The patient suddenly beats his companion, perches himself like a bird on the foot of the bed, grips
his finger in the anus, stands

on

his head, or filths

on

his

88

GENERAL SYMPTOMATOLOGY
Occasionally, aggressive

dinner plate.

and

violent attacks

originate in this way.

In this derailment of impulses one gets the impression that the original purpose in the act is forced into the background;
for instance, the patient will exert the greatest
effort of the will

when

started in a certain direction

when

he could easily succeed by making a little detour. He will push persistently against a locked door toward which he
has started when he could easily leave the room by an open door close at hand.

Diminished Susceptibility of the Will.
of the blocking of the will
it

In the description
cer-

was shown how, under

tain circumstances, every impulse of the will can be rendered The blocking of the will is ineffective by counter impulses.

but a partial symptom of a very general disturbance

;

namely,
will,

the impulsive resistance to every outer influence of the

which by Kahlbaum has been designated negativism.
negativism there
is

In

external impressions, an inaccessibility to social intercourse, and an opposition to every request; and it may even extend to the regular perall

a blocking of

formance of contrary actions (the negativism of command), and finally to the suppression of nature's demands, as in
micturition.

In this way conduct in every respect becomes just the opposite of that which is striven for and that which would

be expected normally. Patients do just the opposite of that which they are requested to do press their teeth
:

together
eyes

when asked when an attempt
refuse

to
is

show

made

their tongue, close the to examine their pupils,

and
they

to

answer
speak

questions

mutism,

sometimes

spontaneously.
will

They

offer

although the
to

most powerful, but almost always
every external encroachment:

passive, resistance

not allow any one to

DISTURBANCE OF VOLITION AND ACTION

89

dress or undress them, will not bathe or take care of themselves, and offer strenuous resistance to compulsory
feeding,

but when unmolested eat greedily.

The

feces

are often retained with the greatest exertion, especially if As soon as they are the patients are taken to the closet.

returned to bed, the evacuation immediately takes place.

They

persist in leaving their

others, likewise they will

although

it

own bed and crawling into smear and spoil their own food, may be even better, and steal or fight for that of
The impulsive character
of its origin is

their companions.

most

clearly

demonstrated in the occasional cases of nega-

Such patients continue lying on their back if requested to arise, or they turn around if asked to go forward, and remain silent if told to speak. Negativism is not due to voluntary opposition. Patients sometimes admit after the attack that they do not know why they acted as they did. Negativism, stereotypy, and loss of will probably all have the same basis. They often occur in the same patient, and may be easily made to pass into one another. These various disturbances of the will are most frequent in catatonia, and are sometimes found in a less pronounced form in paresis, senile dementia, and
tivism to requests.
idiocy.

scious resistance of terrified patients.

Catatonic negativism must not be confused with the conIn catatonia there is

no conscious reason for resistance, and no persuasion can overcome it. It is not influenced by pain, and the manner
of resistance is

always constrained and often absurdly
stubbornness
of
imbecility,
is

in-

appropriate.

The

epilepsy,

hysteria, paresis,

and

senile

dementia

closely allied to

negativism, but in contrast to negativism it always starts with an idea, and is more or less influenced by persuasion,

new

ideas,

and emotional changes.

Moreover, in stubborn-

90

GENERAL SYMPTOMATOLOGY
is fretful, irritable,

ness the general emotional attitude
unruly.

and

The

patient shows

fight,

and

is

often dominated

by confused, malevolent delusions, whereas the negativistic patient shows great equanimity, seldom defends himself, and almost never attacks, but merely resists.
arise

Compulsive acts are those which do not Compulsive Acts. normal antecedent consciousness of motive and from

desire, but

seem

to the

patient to be forced

which

is not his

own.

As a

the morbid impulses;
their approach,

upon him by a will the patients struggle against rule, often caution those about them at

to prevent harm to others. The accomplishment of the act is accompanied by a feeling of relief, and is usually followed by clear insight

and adopt measures

into the nature of the act, accompanied

by chagrin and

remorse.

Compulsory acts are generally accompanied by great emoand stand in close relation to compulsory ideas and fears already described (see p. 69). These disturbances all originate on a basis of congenital morbid endowment, and are all a part of the symptoms of the contional excitement,
stitutional psychopathic states.

Impulsive Acts. Impulsive acts are distinguished from in that they do not seem to the patient to be compulsive acts,
influenced from without, but are the direct expression of a

sudden overwhelming impulse, which gives no chance for
tion or resistance.

reflec-

They

are found in the

most varied morbid conditions.

Probably the pressure of activity in manic forms of manicdepressive insanity is of this type. Here belong also the
wanderings

and

assaults

of

the epileptic

(see p. 446),

the excesses of the dipsomaniac, as well as the morbid

impulses of hysteria, self-inflicted injury, theft, and fraud, Their origin does not lie in definite feelings of pleasure or

DISTURBANCE OF VOLITION AND ACTION
dislike,

91

but in marked motor excitement.

The outbursts

of the catatonic are. thoroughly representative of impulsive acts, although the basis lies not in a pleasurable or un-

pleasurable feeling but in a powerful pressure of movement. The patient is controlled by the consciousness that he must

do

this or that,

without a definite reason and without fore-

thought, although he sometimes appreciates the foolishness of his act. Occasionally there is an idea that his limbs are
controlled

by an

invisible power, as

God, the

devil, or
is

some
domi-

electrical influence.

The

patient 's

consciousness

nated by one blind impulse without clear motive or realization of the outcome. There is no opportunity to resist the
impulse.

The execution

is

tients are correspondingly dangerous.

rapid and reckless, and the paThis is clearly seen

in the impulsive acts of the catatonic, such as the shouting,

sudden attacks, denuding, the senseless attempts to strangle themselves, to cut out the tongue, and to gouge out the
eyes.

A disturbance of the natural impulses Morbid Impulses. is a symptom of all general morbid changes of volitional In paralysis and inhibition of psychic processes all action.
the appetites are diminished; in excitement, on the other hand, appetites are increased, especially sexual desires. The latter seldom lead to actual assault, but manifest themselves
in

ambiguous phrases, abusive language, and by more or

less reckless

masturbation: in women, by shameless exextreme uncleanliness, or incessant washing with posures,
water, saliva, or urine,

combing and unloosing the hair; in adornment and flirtation, by an alternalighter forms, by tion between seductive, shamefaced, and sentimental manners, by hand pressing, letter writing, significant glances, and the like. Less frequently in manic excitement there is found an increased desire for food, although restlessness

92

GENERAL SYMPTOMATOLOGY

usually hinders the patients from taking sufficient nourishment. On the other hand, excessive greediness is not infrequently found in idiots, paretics, and especially in catatonics.

Incredible quantities of the
things, sand,

most unpalatable and
etc.,

disgusting

stones,

seaweed, feces,

are

sometimes devoured by such patients. In these last cases there is not a simple increase of healthy impulses, but probably a simultaneous perversion of the appetite both in nature

and

direction.

The same

is

true of the well-known excessive

by pregnant women. Much more numerous, however, are the morbid sexual impulses, which in recent years have been most thoroughly The most pronounced of these are the coninvestigated. sexual instincts, in which the sexual feelings and desires trary are exclusively directed toward members of the patients' own
desire for eating suddenly manifested
sex.

Sadism consists

in the

attempt to increase or induce

sexual excitement by brutality. In the final stage of its development actual sexual congress is a matter of indiffer-

In masochism, on the other hand, the endurance of pain increases sexual excitation or may be substituted for it. The satisfaction of sadism appears to arise from the
ence.
feeling of absolute

masochism

arises

will of another.

power over the victim, while that of from the most complete subjection to the In fetichism particular articles of clothing
either the necessary adjuncts

or parts of the

body become

for satisfactory coitus, or the simple observation or contact

with the fetich

may

satisfy the sexual impulse.

The most

common
clothing,

fetiches are boots,

shoes, handkerchiefs, underfurs.

and

finally velvet

and

Besides the perversion of normal impulses as seen in the above, there is a group of morbid impulses which seem to

bear no relation to normal

life.

Such are kleptomania, the

DISTURBANCE OF VOLITION AND ACTION
irresistible

93

impulse to steal

all

manner

of worthless

and

things; pyromania, the impulse to burn. Both these usually arise on the basis of an epileptic or hysterical
useless

endowment. The whole series of abnormal impulses are partial symptoms of a general morbid endowment, and indicate conIt is possible that kleptomania and genital degeneracy.
pyromania should be regarded as compulsive acts. impulse appears as an obtrusive compulsion which
sisted as long as possible, while the
is

The
is

re-

performance of the act

accompanied by a feeling of Disturbances of Expression.
their

relief.

ideas, patients express among the most important clews to morbid psychic impulses. full delineation of the symptoms of the various disease

The movements by which feelings, and impulses are

A

types occurs in the clinical portion of this work. In this place we confine ourselves to a few characteristic indications.

by lack of interest, notwithstanding accurate apprehension, by listlessness, strained
is

Dementia prsecox

indicated

attitudes, senseless grinning or laughter, with

sudden im-

petuous movements.

In dementia prsecox the change that

movements is very striking, particularly the loss of grace. The catatonic movements are either stiff and wooden on account of the superfluous tension; or careless and listless as a result of an insufficient expenditure of energy; and again they are gross and awkward because associated groups of muscles are involved in the movements. The naturalness of the movements is
occurs in the character of

destroyed by the tendency to ornamentation, which gives them the appearance of being affected, and finally there is

a lack of uniformity in the movements of expression. Paretics may often be recognized by their awkward
friendliness

and production

of silly expansive ideas.

De-

94

GENERAL SYMPTOMATOLOGY

pressed patients sit around collapsed and flaccid, with troubled expression. Their movements are slow and laborious.

The apprehensive

patients are restless, bite their

In extreme retardation, they nails, and wring their hands. lie motionless in bed with fixed expression and whisper their
answers with great exertion.

The

manic-depressive, on

the contrary, moves rapidly about, talks, cries, sings, plays tricks on his fellows, and busies himself with all sorts of
things.

hair to

The hysterical patients arrange their clothing and make an impression. The paranoiac endures his
him the
all his

hospital confinement with dignity, carrying with

pretensions. Alterations of speech and writing are of the greatest diagnostic value. Delusions are usually betrayed by the content of the communications. In manic patients there

documents which prove

incessant babbling, with a tendency to puns and rhymes. This is also found in excited paretics with more or less disIn both diseases speech may turbance of articulation.
is

be reduced to an incomprehensible gibberish, though from
different causes.

In retarded patients speech

is

low and

difficult.

Melan-

choliacs express their thoughts laconically,

up a monotonous lamentation. for weeks at a time, and then suddenly begin fluently or sing, although more or less confusion
is

and often keep Catatonics are often mute
to speak of speech

always present. Their stereo typy is manifested by constant repetition of the same words, phrases, or even senseless syllables, while they frequently make up entirely new
words.

Disturbances of writing correspond both in content and form with those of speech. The manic-depressive patient fills sheet after sheet of paper with large, showy, and hastily written characters, which are often illegible even to the

DISTURBANCE OF VOLITION AND ACTION
writer.

95

The

paretic's writing

ment

of

words and

uncertainty.
for emphasis.

shows omission, misplacesyllables, blots, untidy corrections, and Hysterical patients use innumerable marks

In melancholiacs the individual characters are incomplete, small, and crowded. The same is true in retardation. Catatonic patients cover the paper with uninwritten verbigeration. repeated In psychoses associated with brain lesions there are apt to be present disturbances of speech and writing such as
telligible scrawls, endlessly

inability to read
syllables,

aphasia, paraphasia, agraphia, paragraphia, perseveration, and to combine letters into words and
indistinct enunciation, scanning or

monotonous
is

speech, also ataxia in writing.

Conduct arising from a Morbid Basis.

Since conduct

the expression of the entire psychic life, we readily understand why it is more or less seriously disturbed by morbid

changes in any part of the psychic individual, while, on the other hand, no isolated act can be taken as an infallible index of the exact morbid condition. Delusions of sinfulness impel patients to penance, self-mutilation, or suicide. Delusions of persecution lead to mysterious precautions, to misanthropic isolation, to restless wandering, or even to

outbursts of rage and murderous attacks against supposed enemies. Hypochrondriacal delusions may lead to revolting smearing, self-mutilation, or injurious and absurd curative attempts, often with the evident purpose of attracting

attention and sympathy.

Mental excitement very soon leads to conflicts with the environment, to breaches of the public order, and quite often to resistance to civic authority. Patients behave in a reck-

and striking manner. They are ungovernable, irritable, and violent under contradiction and restraint. At first they act as if intoxicated, and later become still more restless

96
less

GENERAL SYMPTOMATOLOGY

and even dangerous. There is usually also a tendency to sexual excesses, in which they indulge without regard to decency or morality. Such excited states are regularly ac-

companied by all sorts of mad pranks, destruction of property, adventurous journeys, brawls, and public scandals. When
associated with expansive ideas, the patients purchase large

amounts of useless stuff, prepare and spend large sums of money.
in their neighborhood belongs to

for mythical undertakings,

The idea that everything them induces the patients
happen
on,

to innocently appropriate whatever they embezzlement, or to fraud.
letters to

to

Paranoiacs systematically prepare their claims, address

and publish pamphlets. In notice they appear on the street compel in unusual costumes, attack prominent persons, and create
prominent
officials,

their attempts to

public scandals. Love-letters, proposals, etc., are directed at the supposed secret lover. The religious paranoiac founds

a church and seeks a martyr's crown.

METHODS OF EXAMINATION
IN mental disease
it is

of the

student employ a definite the patient. Any method to be satisfactory must include the (a) anamnesis of the family, and (6) personal history
previous to the disease, (c) the anamnesis of the disease, (d) and finally the status praesens. (a) The importance of heredity as an etiological factor
necessitates a careful consideration of the family history, not only as regards the presence of mental and neurological
diseases,
tion.

utmost importance that the routine method of examination of

This can

but also evidences of defective physical constitunever be elicited by simply asking the

general question if there is a history of insanity or nervous diseases in the family, but it requires a detailed inquiry into the habits, traits, and physical illnesses of all the memstress
tions,
(6)

bers of the direct branches of the family, laying particular upon mental peculiarities, alcoholic and other addic-

personal history should begin with an inquiry into the conditions attending gestation and birth, such as,

and The

criminal tendencies.

exhausting diseases, deprivation, severe emotional shocks, mental anguish, and birth trauma. In infancy there is the

and their sequelae, convulsions, head injury, paralyses and the tardy appearance of walking and talking, and in childhood, the progress in school and conditions accompanying puberty and menstruapresence
of

infectious

diseases

masturbation, sexual impulses, emotional manifestations, timidity, morbid tempeculiar
H
97

tion, also the existence of

98

GENERAL SYMPTOMATOLOGY

peraments, religious experiences, etc. If married, the conditions attending child-bearing should be known, as well as severe illnesses, such as, typhoid fever, injuries, mental
shocks,

and deprivation; and

if

employed, the character of

the work, the materials handled, the sanitation and undue
physical

and mental strain, excessive indulgence in eating, Perdrinking, and amusement, and also drug habituation.
idiosyncrasies,

exaggerated egotism, one-sided intellectual development, with attainments in one field and
sonal
lack of development in another, should be included in your
list

of inquiries.

In

eliciting

such facts

it

should be borne in

It general questions are wholly inadequate. requires close and detailed questioning, and even then important facts are very apt to be overlooked.

mind that

In determining the cause of the disease one should guard
against mistaking for causes the actual early symptoms of disease; such as the excesses of the paretic, the self-con-

demnation of the melancholiac, and the masturbation
hebephrenic.
(c)

of the

the anamnesis of the disease particular attention should be paid to the character of the onset and the
eliciting

In

In securing this information it is usually most satisfactory to follow out the outline prescribed for making a mental status; i.e. elicit information concerning the

symptoms

to date.

presence of hallucinations or illusions at various periods, of disorder of orientation, attention, memory, train of thought,

judgment, and in the emotional and volitional fields. It is often difficult to determine the actual date of onset
of the disease because the initial

change in disposition

is

sometimes so insidious that the true significance of certain peculiarities is not appreciated until emphasized later by the
occurrence of the more striking symptoms. In case there have been one or more previous attacks of mental disease

METHODS OF EXAMINATION
there should be the

99

same

careful inquiry not only into the

character of the
their duration,

symptoms presented at these periods and
some
field of

but also particularly as to whether the patient

fully recovered or suffered residual defects in

the mental

life.

(d) Status prcesens.

This ^examination should include ob-

servations of both the physical and mental conditions of the patient. In view of the fact that many persons are
particularly sensitive about undergoing a mental examination it is desirable to begin with the physical examination. Dur-

ing it there is always opportunity to frame questions in such a way that the answers will give valuable information as to the mental state; as, for instance, the memory can be

determined by questions as to the date of appearance of certain physical signs, or the orientation may be ascertained

by questions as to those who are caring
their food
is

for them,

by

whom

prepared, etc. Indeed, the great variety of physical symptoms to be inquired into offers sufficient chance to cover all fields of the mental status; even hallucinations

and

illusions of hearing

and

sight

may

be disclosed by the

examination of the senses of hearing and sight. The general survey of the body should include the state
of nutrition, the present

body weight compared with

earlier

weights, the presence of anaemia or cachexia, signs of premature senility, or delayed pubescence, also evidences of socalled physical stigmata, as harelip, malformation of the palate, of the ears, or sexual organs, albinism, congenital

strabismus, malposition of the teeth and eyes, etc. Trauma, scars, and residuals of previous diseases should not be overparticularly those of syphilis. The physical examination should be careful enough to eliminate such

looked,

and

chronic nephritis, uraemia, diabetes, pernicious anaemia, Graves' disease, tuberculosis, syphilis,

chronic diseases

as

100

GENERAL SYMPTOMATOLOGY

lead poisoning, and chronic gastritis. The condition of sleep and of the gastro-intestinal tract needs special attention because of the frequency with which disturbances exist
in these fields.

In the examination of the nervous system, the measurements of the cranium will give some indication as to the

development of the cortex, but it is of more importance to observe the disproportion between the cranium and the rest
of the body.

The circumference

of the skull taken along

the line just above the external occipital protuberance and the glabella should measure in an adult between 48 and 56
centimeters, while the distance between the extreme lateral points as taken by craniometer should be between 14 and 15

centimeters. The examination of the eye grounds should not be omitted, as it often reveals vascular sclerosis, which might otherwise escape notice. Likewise, a careful ex-

amination of the ears sometimes discloses a
for peripheral hallucinations.

sufficient cause

Then the muscular system should be examined. First determine the condition of muscular tonicity by employing passive movements and examining the tendon reflexes.
Both of these may be difficult on account of lack of cooperation and inability to secure complete relaxation of the limbs;
hence

important to have the patients in a comfortable and restful attitude, such as in a recumbent position, with
it is

by engaging them in conversation, giving them figures to add or something to read aloud. In eliciting the knee jerks, if the patient is lying on his back, place left hand beneath the knee and gently lift it, allowing the foot to rest on the bed. If you find the leg relaxed, strike
their attention distracted

the tendon at any time.
relax until
will

Frequently the patient will not have raised the knee high enough so that it you
itself in

support

that position.

If the patient is sitting,

METHODS OF EXAMINATION

101

he should recline backward in an easy posture, with both feet
squarely on the floor and brought as far forward as possible without causing the toes to leave the floor.

The ankle clonus is best elicited now by slipping the right hand under the toes and sole of the foot and quickly jerking
the foot

upward

for a

few inches, so that the weight of the

elevated leg and thigh rests on your hand. The Achilles is determined by asking the patient to stand leaning jerk

forward and supporting his weight by placing his hands on the top of a table or back of a chair. The ankle is then
lifted in the rear

tendon

is

and allowed to rest on your knee, when the struck. The wrist and jaw reflexes should also be

determined.

The muscles should be examined further by palpation and by the exercise of active movements which will determine the
presence of paralysis (flaccid, spastic, or accompanied by Such contractures), as well as disturbances of coordination.

movements are the voluntary
is

raising of the legs while the

patient recumbent, attempts to touch the knee, to touch the end of the nose with the forefinger with or without closed eyes, standing erect with eyes closed and feet close
together, closing the eyes, opening the mouth, and protruding

the tongue upon command, and then reversing the order. These tests should also include voluntary writing, and speech,
as well as the enunciation of different words, such as "electricity," "Massachusetts artillery brigade," "around the rugged rock the ragged rascal ran." The movements employed above will also demonstrate tremors (fine, coarse, fibrillary,

and retractile of the tongue), which should be noted. The mechanical irritability of the muscles and the nerves is then determined by percussion of the muscles, and the mechanical stimulation of the peripheral nerves. The nature
of

spasms should also be investigated

(epileptic, hysterical,

102
choreic,

GENERAL SYMPTOMATOLOGY
Finally, the irritability of the muscles nerves to electricity, wherever there are indications for

and athetoid).

and

its use,

should be determined, since disturbances in it as well as in all of these other fields may have distinct bearing
condition.

upon the general brain

Following this the sensibility should
hypersesthesia, analgesia,

be tested, including

the sensations of pain, touch, and temperature, for areas of

and

paraesthesia.

For

this pur-

pose the simplest implements are the best; namely, a camel' shair brush, a needle, and small bottles of hot and cold water.
It

may also be necessary to examine the stereognostic sense.
Vasomotor, secretory, and trophic disorders should be

recognized and recorded, particularly cyanosis of the extremities,

dermography, glossy

skin,

canities,

alopecia,

ony-

chogryphosis, naevi, herpes, scleroderma, the various trophic disorders of the bones

and hyperidrosis; and joints, includ-

ing spontaneous fractures and hsemotama auris. In the examination of the pulse there is nothing to be

found peculiarly characteristic of any special form of mental

and depressive states is usually elevated, and depressed in manic states, corresponding with the vasomotor symptoms ordinarily accompanying these states. The fall in blood pressure observed in the end stages of paresis is in accord with the progressive terminal cardiac weakness. The examination
disease.

The blood

pressure

in

fearful

been thus far unproductive of characteristic In any given psychosis the blood states may disorders. vary considerably in the different stages. In the psychoses
of the blood has

studied by us
1

1

dementia prsecox, manic-depressive insanity,
in

"Blood Changes

Dementia Paralytica," American Journal

of

Med.

Soc., Vol. 126, p. 1074.

"A

Contribution to the Study of Blood in Manic Depressive Insanity,"
of Insanity,

American Journal

LIX, No.

4,

1903.

METHODS OF EXAMINATION
and dementia paralytica
istic

103

the only apparently characterblood states were those found in dementia paralytica,

where there was a progressive anaemia and a progressive increase of polymorphonuclear leucocytes accompanying
the advancing course of the disease and the presence of a The chemical leucocytosis accompanying paralytic attacks.
investigations of the urine, gastric contents,

and

of

body

metabolism, while still fruitful fields for study, do not warrant routine examinations except in the matter of urine and gastric
contents to obtain indications for treatment.
careful physical examination should include in doubtful cases the examination of the cerebrospinal fluid for the pur-

A

pose of differentiating between functional or organic disAs much depends upon the technique, the method eases.
is briefly

stated.

With the

strictest aseptic precautions the

needle

is

vertebrae,

inserted between the fourth and fifth lumbar and three or four centimeters of fluid withdrawn.

This

is
is

speed

if the immediately centrifugalized 10 minutes if only 2500 revo3000 revolutions, or 30 minutes

lutions can be obtained.

The supernatant fluid is poured out of the glass and then a pipette is carefully introduced into the bottom of the tube and the sediment all withdrawn.
is

This

thoroughly mixed by blowing
it

it

out into the tube and

sucking

up

again,

when

three drops of equal size are

slides, which are allowed to dry in the air. The slides are fixed by a half-hour immersion in equal parts of absolute alcohol and ether, stained with a few drops of

dropped on three

Unna's polychrome methylene blue, washed in water, then in alcohol, cleared in xylol, and mounted in balsam.

With a magnification of 300 to 400 times the presence of three
or four lymphocytes in a single field may be regarded as normal. At least three lumbar punctures are necessary
for

a

final decision.

The

bacteriological examination of the

104

GENERAL SYMPTOMATOLOGY

cerebrospinal fluid as well as of the blood has thus far yielded such varying results in the hands of different observers that

a routine examination cannot be recommended for diagnostic purposes.

The most

difficult

part of the examination

mental status.

In this matter much

securing the depends upon the
is

acuteness of the observer, as the patient often enough cannot

be depended upon for cooperation. Unfortunately, we have no scientific standards for determining the mental symptoms,

but must depend upon the simplest psychological

tests;

namely, the asking of questions. For convenience and thoroughness of examination

it is

most important to always have before one an outline

of the

method of examination. If for purposes of record or otherwise, and particularly in medico-legal cases, it is necessary to write down the observations, it is always best to write in full the question and the answer verbatim as given by the patient. Upon subsequent examinations the same questions should be asked, and the answers compared. The general
arrangement
of
this

outline

should

follow

closely

the

presentation of the general symptomatology; i.e. disturbances of perception, clouding of consciousness, disturbances
of apprehension, of attention, of

memory,

of orientation, of the

train of thought, of judgment, of the emotions,
tions.
1.

and

of the voli-

Disturbances of

sions).
elicited

Perception (hallucinations and illuHallucinations can oftentimes be most readily
directly
if

by asking the patient
if

he hears voices or about him.
Fre-

sees pictures or visions, or,
if

this question is not understood,
is

he hears noises or voices when no one

quently the patient does not consider the hallucinations as a
peculiar sensory experience
negatively.

and

will

answer your questions
closely as to

Then he should be questioned

METHODS OF EXAMINATION
how he
sleeps nights,

105
is

and whether or not he

disturbed.

Again, he
associates,

may

be questioned as to whether or not intimate

shopmates, employers, or business associates, whom you know to be absent, converse with him. Such questions often elicit the desired evidence of hallucinations.

Sometimes sense deceptions are
for instance,

elicited only

when one

seeks

for the basis of certain delusions held

by the patient, when,

will admit that he believes he is persecuted remarks that he hears. Patients observed assuming listening attitudes and addressing remarks to unseen persons, or gesticulating earnestly in a definite

he

because

of

good be regarded as suffering may from sense deceptions, although these are denied by them when questioned directly. In the matter of religious
food without adequate reason,
hallucinations, such as the voice of God, one should be " " voice of conscience particularly careful not to mistake the

direction, or persistently spitting out or casting aside

or the

"

voice of the heart

distinction

which some

as genuine hallucinations, a patients are loath to admit. Again,
to be true hallucinations

"

sometimes what in

many appear

are not such, but are really genuine perceptions. In this matter one cannot exercise too great care. What has been

indicated in reference to hallucinations

and

illusions of sight

and hearing
2.

refers equally well to the hallucinations

and

illusions of the other senses.

Clouding of Consciousness and Disturbances of ApThe determination of unconsciousness, of prehension.
befogged states, and of diminished sensibility depends mostly in clinical practice upon the patient's reaction to definite
stimuli, such as

one uses in any neurological examination ; namely, the test of pain and touch sense by the use of the
needle, of hearing by the use of speech, of sight by writing tests or the perception of colors. Further, the compre-

106

GENERAL SYMPTOMATOLOGY

hension of simple or confused pictures (medleys) placed before the patients gives an insight into these defects.

such as Hipp's chronoscope and the apparatus of Ranschburg, have been devised for the accurate determination of the process of perception, which are not

Many elaborate

tests,

wholly suitable for general application or for bedside use. Attention (blunting, blocking, 3. The Disturbances of and distractibility) can usually be retardation, passivity,

determined in a satisfactory manner by the use of the progressive adding and subtracting test, such as, subtracting 7 successively from 100 down to 0. The variations in the
rapidity and the occasional blocking afford good demonstrations of the stability of the attention. The introduction of distracting influences during the test, such as dropping a

cent upon the floor, will bring out distractibility of attention. In the application of such a test one must always take into account the social grade of the individual as well as the degree
of his education.
4.

Memory
is

(defects

in

the

impressibility,

retentiveness,

accuracy, and
of

fabrications of memory).

The

retentiveness

usually determined by a series of questions directed toward the retention of certain school knowledge,

memory

such as the multiplication table ; or the uninterrupted adding or subtracting of 3, 7, or 12, the time required being measured

by a stop-watch.

The

retentiveness in patients sensitive

to being subjected to such tests can be estimated only
facts in history.

by

asking questions concerning the past personal experiences or
readily determined by asking the patient to repeat numbers of more than one figure which are dictated to him ; also unfamiliar
impressibility of

The

memory can be most

combinations of syllables. This may be done both orally and by writing. Again, he may be asked to recognize in a

METHODS OF EXAMINATION

107

group of pictures a certain picture which has previously been shown to him. Questions directed to ascertaining recent occurrences in their daily lives, such as what he had
for dinner yesterday,

what the nurse or doctor

him,

may

be asked.

is doing for In the determination of both the

retentiveness

and

impressibility one

must never demand

from an uneducated person more than he ever acquired. The accuracy of memory and the fabrications will already have been elicited by the questions asked in reference to
remote and recent personal experiences.
5.

Orientation

(apathetic,

orientation
place,

and

perplexity).

amnesic, and delusional disThe orientation as to time,

is determined by such questions as: the date of the month, the day of the week, and " " the season and year? Where are you now? " " What

and persons
is

"

What
the

is

name of the place,
"

of the building

of the city?

"

and its character, and

Who
is

duty here,

and what

are these persons about you, their " In case the your mission here?

patient is not disposed to or is unable to respond, his orientation as well as his power of apprehension can be determined

by watching

carefully his conduct in his environment; for instance, noting the names with which he addresses his
associates, his religious observances, his ability to find his way about in familiar environment, etc.
6.

Train of

Thought (paralysis

of

thought, retardation

of

thought,

compulsive ideas, simple persistent ideas, per-

severation, circumstantiality, flight of ideas, desultoriness). If the patient is at all communicative and has answered the

foregoing questions, you already have to judge of the wealth of his store of
its

had some opportunity
ideas, or the degree of

impoverishment,

if

present; also to

other disturbances of the train of

some extent of all of the thought, and particularly

the retardation of thought.

If the patient is productive

108

GENERAL SYMPTOMATOLOGY

and volunteers much speech, there

is usually little difficulty of simple persistent ideas, cirin determining the presence cumstantiality, flight of ideas, and desultoriness. In case

the patient

not productive, the disturbances in the content of thought can be elicited by requesting him to recite connectedly the incidents of some recent personal experience;
is

such as the detailed account of the nurse's method of caring for him or the account of the journey to the hospital. It
" " Is that Yes, yes," or, tinually urge him by interjecting " In this way circumstantiality, flight of ideas, and so? desultoriness is usually detected. Another method is to

may be necessary in

order to keep the patient talking to con-

peruse the voluntary writings of the patient, particularly

home

letters.

There are

many more

associations of ideas.

Of

accurate tests for determining the these, the one most easily carried

out at the bedside is to give the patient any sort of a word, such as "horse," and then ask him to speak aloud the ideas
arising in his mind, which you may write down, or you ask the patient himself to write down all ideas occurring may to him in a definite period of time after being given the initial
first

way one can obtain some conception of the between the inner and external associations, of relationship
word.

In this

the prominence and frequency of fixed associations, senseless and sound associations, of Uniformity and the desultoriness
of the train of thought, as well as the wealth of the store of
ideas, the tendencies to

sudden

cessations, or the tenacious

holding of a single idea.

Usually by the time one (delusions). has reached this stage of the examination real delusions
7.

Judgment

have been actually expressed or some hints have been accidentally dropped which will serve as a basis for further
questioning.

In determining delusions, direct questions

METHODS OF EXAMINATION
are less pernicious than in eliciting

109

some

of the other

mental

symptoms. One may ask the patient if he is troubled in any way, if the affairs at home are moving smoothly, if his business is successful, and if he is at all apprehensive
of his welfare, etc.

Should your patient show considerable

reserve

refuse to speak of personal matters, as often happens immediately after his liberty is restrained or he is placed in a new environment, one must be tactful in approach-

and

ing the matter of delusions. Sometimes the simple direct question as to why he has been deprived of his liberty or

submitted to the care of the physician may be sufficient. Again, it may be necessary to introduce a subject of much interest to him, such as his employment, literature, or travelasked to express his judgment as to cost of manufacture of the material with which he works, the
ling,

or he

may be

contentions of trade unions, the utility of trusts, or his opinion of the countries in which he may have travelled. A
free discussion of a

matter of general

interest,

but at the same

time bearing upon the individual's livelihood, usually uncovers some of his delusions, if any be present. In the case
of women, domestic difficulties, church or social relations, and especially neighborhood differences, are usually fruitful The various somatic sources for discussion and inquiry. delusions are most often brought out by questions as to the health of all the various organs of the body. The evidence of systematization of delusions can often be best determined " What is the object of all this? " or, by asking directly,

"

Do

" these various ideas bear any relation to each other ? Defective judgment in other matters than delusions will

usually be established by such general discussions as those " What do you think advised above or by such questions as, " " of the restriction of your liberty? How much does it " cost you to live ? "Are you receiving sufficient wages, and

110

GENERAL SYMPTOMATOLOGY
live

" " within your income? Figure up your cost " of living." Who aids in the support of your family, and do they do as much as they should? " etc.

do you

Emotional Field (emotional deterioration, increase emotional irritability, sad disposition, irritable disposition, of
8.

seclusiveness,

sunny

disposition, fanaticism, morbid frivolity,

fear, phobias, dejection, sadness, feelings of pleasure, feeling

of well-being, disturbances of hunger, nausea, pain,

and
of

of

the sexual feelings.)

In this

field

one has to depend rather
the

more upon observation than upon interrogation

patient, as there is large opportunity for simulation and Most patients if asked if they loved their parfalsehood. " Yes " even though they might be totally ents would say

and exhibiting profound emotional deterioration. One rather has to rely upon the observations of others as to relations which the patient maintains with his family, in his work, and in his social environment, which would exhibit increased and diminished emotional Likewise one irritability and persistent sadness or elation.
barren of
all

affection

cannot depend upon the patient for accurate observations as to whether or not he is of a sad, sunny, seclusive, or irritable disposition, or given to fanaticism or morbid frivolity.

The

persistent feelings of fear, of sadness, and of well-being usually become apparent to one during a prolonged examina-

tion

and do not need

special inquiry.

Yet

in this matter

one sometimes must ask the patient directly how he feels, or whether or not he is fearful or dejected. The disturbances
of the general feelings of pain, of hunger, nausea,

and

of

the sexual

of the conduct than

more readily determined by observation by questioning. In questioning those most intimately associated with the
life

are

patient one may ask such questions as these whether or not there has been a change of disposition; previous to illness
:

METHODS OF EXAMINATION
was the individual of a sition; was he fond of
sociable, cheery, or

111

melancholy dispo-

solitude,

now fond

geous, irascible, suspicious, of his family or apathetic,
obligations, or
is

was he silent, timid, couraor proud and egotistical; is he
is

he

fulfilling his

family

he negligent, disrespectful, or insensible to the feelings and interests of others; is he fulfilling his religious obligations, or does his general conduct

and business

show unnatural

fear, sadness, or exaltation.

We have at best no very accurate means of measuring the
Feelings of displeasure, of pain, fear, and anger can be created experimentally in various ways and by hypnosis, and the latter method has been employed by Lehmann to determine the
life

emotional side of the

of the patient.

upon respiration, pulse rate, and blood pressure. Furthermore, the writing scale and the ergograph, which are used to measure the finer expressions of the will, are serviceable in measuring the outward expressions of emotional excitement.
9.

influence of emotional states

Volitional

Field

(paralysis of

the

will,

pressure of

activity,
will,

psychomotor retardation, stupor, blocking 0} the muscular tension, hypersuggestibility of the will, catalepsy,

cerea flexibilitas, exhopraxia, distractibility of the will, interHere also ference, stereotypy, mannerisms, negativism).

one must depend to a large degree upon observation of the conduct, both spontaneous and in obedience to command or
suggestion.
paralysis of the will can be determined by watching the patient's voluntary movements, also the reaction in response to the call to dinner or when requested

Thus

to attend
tion,

some simple duty. Pressure of activity, retardastupor, and blocking of the will, as well as muscular

tension, are usually evinced before one has reached this stage of the examination. The methods of physical examination

are sure to bring out these defects as well as cerea flexibilitas

112

GENERAL SYMPTOMATOLOGY

and catalepsy. If not, one has simply to grasp the arm and place it in an awkward and uncomfortable position or to
patient to perform certain movements, as walking, shaking hands, or writing. If negativism is presDistracent, it also will be elicited by these methods.
tibility of

command

the

the will, interference, stereotypy, and mannerisms

are elicited

by similar commands. The observation of the conduct by nurses and others should be inquired into, as in this way the varying periods of mutism, negativism, muscular tension, and tendency to eat the food of others and to get into others' beds, to stand in awkward and statuesque positions, can be elicited, which

may

In the

not be present at the time of your examination. finer analysis of disturbances of volition, partic-

ularly psychomotor excitement, retardation,

and

tension,

Kraepelin suggests the writing scale, by which one can determine the path of the writing, the rapidity, and the pressAlso the ergograph, invented by Mosso, can be employed to measure the strength of the movement, the effect
ure.

of retardation, fatigue,

and muscular

tension, as well as

the rapidity with which the contraction and relaxation of the muscles follow under the influence of the impulses of the Both of these instruments, however, have their will.

drawbacks which render their routine application unsatisfactory.

The more

severe disturbances in the release of the

volitional impulses can be measured by the use of the watch, such as in counting as rapidly as possible from 1 to 30, rapidly repeating the alphabet, or in simply raising the arm.

FORMS OF MENTAL DISEASES

CLASSIFICATION OF MENTAL DISEASES
CONSIDERATION OF THE FACTORS ENTERING INTO A PROVISIONAL CLASSIFICATION
*

THE principle requisite in the knowledge of mental
is

diseases

definition of the separate disease processes. In the solution of this problem one must have, on the one

an accurate

hand, knowledge of the physical changes in the cerebral cortex, and on the other of the mental symptoms associated

with them.

Until this

is

known we cannot hope

to under-

stand the relationship between mental symptoms of disease and the morbid physical processes underlying them, or in-

deed the causes of the entire disease process. There are still other difficulties to be encountered in obtaining that

fundamental knowledge necessary for a scientific classification of mental diseases. In the first place, it is almost to establish a fundamental distinction between impossible
the normal and the morbid mental state, as was frequently indicated in our discussion of the general symptomatology. It is equally difficult sometimes to distinguish between the
transition states existing between different forms of recognized types of mental disease. Again, the symptoms of the
disease are apt to be greatly influenced and exaggerated by the morbid hereditary basis which underlies so many forms
of

mental disease.

Finally, as the functions of different

parts of the brain differ, hence the character, intensity, and location of the morbid process influence greatly the gradations in the

form of the mental disease.
115

116

FORMS OF MENTAL DISEASES
no sure foundation upon
Never-

Clearly, then, there is at present

which to construct a
theless, there is

final

standard classification.

always a demand for some grouping of our

knowledge as a basis for practical work, particularly in teaching. Judging from experience in internal medicine,
the safest foundation for a classification of this kind
is

that

offered by pathological anatomy. Unfortunately, however, mental diseases thus far present but very few lesions that have positively distinctive characteristics, and furthermore

there

is

the extreme difficulty of correlating physical and

mental morbid processes. Likewise it has been impossible thus far to establish a classification upon an etiological basis. Although there are

some agents that produce very definite symptoms, such as alcoholic intoxication, certain acute infectious diseases,
head
injury,

and

particularly the

more profound types

of

hereditary degeneracy, yet very many sanity are wholly without any distinctive etiological factors. And furthermore, one often has to admit that any single

individual cases of in-

pathogenic factor
of

symptoms. work in conjunction with each
difficult to ascertain

itself known by a great variety the causes of mental disease often Again,

may make

other, rendering it extremely the relationship between the causes and

the symptoms.

The most popular method
has been the so-called

of classifying

mental diseases

clinical

classification.
is

The grave

apt to be an overvaluation of some symptoms resulting in the accumulation in one group of all cases having in common some one
defect here arises from the fact that there

symptom. In this way all sad and anxious emocame to be regarded as melancholia, all excited states as mania, and delusional states accompanied by hallucinations as paranoia. The difficulty becomes apparent
striking

tional states

CLASSIFICATION OF MENTAL DISEASES

117

when a
tial,

single case thus classified presents during its course the characteristics of several groups. It is, therefore, essen-

as

was pointed out by Kahlbaum,

to distinguish beitself.

tween transitory mental states and the disease form

The

conception of the disease demands knowledge not only of the present state, but also of the entire course of the disease.
scientific

Judging from our experience in internal medicine
fair

it is

a

assumption that similar disease processes

will

produce

identical

symptom

pictures, identical pathological

anatomy,

identical etiology. If, therefore, we possessed a of any one of these three fields, comprehensive knowledge

and an

we pathological anatomy, symptomatology, or etiology, would at once have a uniform and standard classification A similar comprehensive knowledge of of mental diseases. either of the other two fields would give not only just as uniform and standard classifications, but all of these classifications would exactly coincide. Cases of mental disease in the same causes must also present the same originating symptoms, and the same pathological findings. In accordance with this principle, it follows that a clinical grouping of psychoses must be founded equally upon all three

which should be added the experience derived from the observation of the course, outcome, and
of these factors, to

treatment of the disease.

In the classification presented here there are treated
of all those forms of insanity that are

first

produced by

external

namely, those psychoses that arise in connection with infectious diseases, those that follow upon severe excauses;

haustion, and finally those produced Next are considered the psychoses

relation to the products of intoxication. Our knowledge of these

by intoxicating agencies. presumed to bear some faulty metabolism and autois

definite only in

118

FORMS OF MENTAL DISEASES

reference to thyrogenous insanity; but there are certain points of similarity which would indicate that dementia prse-

cox and dementia paralytica should also be classed here. The forms of insanity arising from diseases of the brain,
the organic dementias, comprise the next group. Here external causes also play some role, as, for instance, the
syphilitic lesions,

head

injury,

and cerebral embolism.

Next
:

come the

insanities associated

with the involutional period

melancholia of involution, senile dementia, and the presenile state with delusions of prejudice.

The next group comprises manic-depressive insanity in which a morbid constitutional basis occupies a prominent The same condition obtains to a still more marked position.
degree in that gradual morbid transformation of the entire psychical personality designated paranoia, which is described
next.

In epileptic insanity, which comes next, besides the

prominent morbid constitutional basis, there often exist other morbid conditions as head injury, arteriosclerosis, and
infectious diseases.

The

epileptic attacks

sometimes date

from some particular revolution in the physical organization.
These facts give to epilepsy an intermediate position between auto-intoxication, organic brain disease, and heredi-

We do not, however, believe that tary mental diseases. the disease group recognized to-day as epilepsy presents a
clinical unity.
it

Further knowledge probably will disclose in In hysteria, while the several different disease processes.

faulty constitutional basis is prevalent, the various forms of mental disorder seem to be released wholly through the

action of the emotions.
Closely associated with hysteria are the insanities of degeneracy. The morbid constitutional basis encountered here
varies greatly

and

it is

often impossible to differentiate the

CLASSIFICATION OF MENTAL DISEASES
several different forms of psychosis.

119

Yet one may formulate

two

large groups

;

namely, the constitutional psychopathic

and the psychopathic personalities. The former comthose morbid constitutional states which are recognized prise by being more circumscribed, as developing gradually at first,
states

or as appearing only at times; the latter include the characteristic morbid developmental forms of the entire psychic personality, which are justly regarded as an expression of

degeneracy. In some instances this division is inadequate. Finally there are described those forms which indicate a

ment

an incomplete developSometimes the basis for this lies in a faulty development of the body, but more often there exist in the undeveloped brain disease processes, which
restriction of

mental development

of the psychical personality.

produce a partial destruction of the tissue, thereby rendering mental development impossible. Strictly speaking, these latter cases should be regarded as organic brain diseases.

We

are not yet in a position to distinguish accurately between restricted development and diseases of the brain,

and furthermore, the mark of congenital weakness predominates to such a marked degree in the clinical pictures that any distinction between both of these groups which are so intimately related from an etiological standpoint
itself. Indeed, we might go even a step and consider these forms of defective development as states of mental weakness which were produced by

hardly

commends

farther

profound mental disease in the earliest stages of development. Also in these cases the development of psychical
personality

was destroyed

at the outset.
it

In concluding the subject

should be emphasized that

many

of the disease pictures differentiated in the following

pages are but attempts to present a part of our observations in a form suitable for teaching purposes. It must be

120

FORMS OF MENTAL DISEASES

admitted that even to-day it is impossible, in spite of honest efforts, to create a "system" of psychiatry that will include all cases. Attempts of this sort that have been made only
bring confusion. While this assertion may prove somewhat disquieting to the student, to the investigator it means a frank acknowledgment of real conditions and an honest
effort

to establish accurate
clinical experience.

and fundamental knowledge

from our

I.

INFECTION PSYCHOSES
disturbances here described are supposed from toxins of infectious diseases.

THE mental
They

to develop primarily

are fever delirium, infection deliria y

and

post-febrile

psychoses.
of the fever,

Fever delirium follows rather closely the clinical course and in a measure depends upon it. The

infection delirium corresponds to the initial deliria of other authors, appearing at, or near, the onset of infectious dis-

The remaining group includes eases, independently of fever. the various forms of mental disturbance which follow the
infectious disease, developing during or following the fever,

permanent mental enfeeblement. Other writers describe these under the various diseases which they accompany; as, typhoid delirium, pneumonic delirium, influenza insanity, and insanities following exanthemata. The mental symptoms arising from the toxins of the different infectious diseases cannot as yet be suffito
ciently differentiated to permit of their being considered as characteristic of the corresponding disease. The only

and which are apt to lead

istic of

distinguishing features are the physical symptoms characterthe different diseases. It is still a question whether

the changes in the cortical neurones are due directly to the toxins produced by the micro-organism, or to an autotoxin

developing within the body as a result of the infectious
disease.

A.

FEVER DELIRIUM

The

clinical picture of fever delirium presents four differ-

ent grades

corresponding to the intensity of the toxic
121

122

FORMS OF MENTAL DISEASES
upon the
cortical neurones, varying

action

from moderate

irritation to paralysis

Etiology. fluence on the type of delirium, which apparently is modified only by the rapidity of the development of the fever, its
intensity,

and finally to complete destruction. The form of febrile disease has very little in-

and duration.

There seems to be

little

ground

for

the claim that the mental disturbance occurring during typhoid is more or less characteristic. Besides the toxin

produced in the febrile disease, the rise in temperature, acceleration of metabolism, and disturbance of circulation should be regarded as causative factors. In addition there should be included alcohol, which plays such an important
role in

pneumonia, giving rise to symptoms characteristic of delirium tremens, such as illusions and hallucinations of
objects of great sensory vividness, the occupation delirium, tremor, and a mixed emotional state showing both elation and anxiety. Furthermore, the individual's

many moving

power

of resistance

is

of importance.

It is well

known

that children, women, and nervous men show a tendency to develop delirium with any severe form of fever.

The

pathological

ance of the cortical cells very similar to that

anatomy exhibits mostly a disappearwhich can

be produced experimentally by the application of superheated air to test animals as well as many other deleterious
agents.

Symptomatology.

In the lightest grade of fever

delir-

ium

is irritability, some restlessness, general hyperinsomnia with anxious dreams, a feeling of numbsesthesia, ness in the head, and a desire to be left alone.

there

In the next grade there
sciousness;
illusions

is

a marked clouding of conlargely

and hallucinations

dominate

The ideation, producing a dreamy confusion of thought. designs on the carpet and ceiling appear as moving forms

INFECTION PSYCHOSES

123

or grinning faces, the bedpost assumes the form of an Frightful outcries or beautiful music are heard, angel. patients have airy floating sensations, and are led about

These dreamy experiences are interrupted momentarily by a return to The emotional attitude becomes normal consciousness. either much exalted or depressed, and motor activity inthrough gorgeously decorated rooms.
creases greatly.

In the third grade the disturbance of

consciousness

becomes very pronounced. The patients prattle constantly, the content of thought showing even greater dreamy confusion. There are many varied emotional outbreaks and frequent wild impulsive movements, which soon become irregular and uncertain, indicating the onset of paralysis.

The

intense restlessness

is

interrupted by short periods of

sleep.

In the fourth grade the movements become absolutely At this time carphologia appears with subpurposeless. sultus tendinum. The utterances become indistinct, and
consist in

mumbling over incoherent words and

sentences.

From

this the patient

may

enter into a state of

coma

vigil,

open eyes, he is oblivious to and unable to indicate his desires. roundings
when, in spite of

all his sur-

The urine

and fseces are passed involuntarily. The intensity of the motor activity varies in different individuals, sometimes reaching an extreme degree and at
other being confined to spasmodic twitching or choreiform movements of the extremities, or merely of the
face
tion.

and tongue, the

latter

producing peculiar enuncia-

Course.

The duration

of the psychosis in three-fourths

of the cases does not

extend beyond one week, and usually

the delirium subsides with the temperature.

Some

of the

124

FORMS OF MENTAL DISEASES

delusional ideas held during the disease for a long time.

may be

retained

The
of the

prognosis
initial

is

disease.

naturally poor because of the severity If the delirium advances to the

third or fourth grade, at least one-third of the cases die. Where there is hyperpyrexia the prognosis is extremely

doubtful.
into

A few cases emerge from the fever delirium an exhaustion psychosis, or may end in dementia.
the delirium

may be the starting-point of other as manic-depressive insanity, dementia prsecox, psychoses, or dementia paralytica.
Finally,

Besides the treatment of the initial disease, the ice cap should be applied to relieve cerebral hypersemia. Cold

baths or cold packs with friction are most serviceable. In case of cardiac weakness one must be cautious in the
use of the bath, and
lant.

necessary administer a cardiac stimuFor this purpose strong coffee is valuable. Antiif

pyretics are not only useless, but often aid in producing and One of the most important intensifying the delirium.

indications

constant attendance, both to prevent harm to others and injury of the patient by escaping out of doors
is

or jumping out of windows.

If

the excitement becomes

excessive, one should resort to the prolonged

warm bath

This measure rarely fails to bring quiet. In (see p. 140). addition, however, a clever, reassuring nurse is most essential.

The method
sheets so

of

applying

much

in

vogue in
it

pitals should be decried.

and restraint private homes and general hosIf impulsive movements are
strait

jackets

sides, or to resort to padded rooms. The use of hypnotics and narcotics is harmful and distinctly contraindicated. Furthermore, the proper use of hydro-

a prominent feature, padded beds with high

may

be necessary to improvise

therapy usually renders their administration unnecessary.

INFECTION PSYCHOSES
B.

125

INFECTION DELIEIA

This group comprises psychoses which appear to stand
in intimate relationship to the specific toxaemia of certain infectious diseases, including the initial deliria of typhoid

and smallpox and the deliria accompanying malaria, acute chorea, and influenza. There are also grouped here deliria that develop in some septic states, as well as those occurring in toxic states of a less specific nature and presenting the " course of the so-called Acute Delirium." Initial Deliria. the infection deliria, the initial deOf lirium of typhoid is best known. Nissl has reported on the pathological anatomy in one case in which there was
distention of the vessels of the cortex, with increase of white

blood corpuscles and pronounced degenerative changes in the nerve cells. The cell bodies were swollen, the chro-

mophiles were dissolved, and the processes diffusely stained for some distance. Karyokinesis was observed in nuclei of

These changes, which are similar to those produced by experimental intoxication, tend to prove that we have to do with a psychosis depending upon inthe glia
cells.

toxication.
l Aschaffenburg distinguishes two forms of initial delirium of typhoid. In the first the delirium is not accompanied by

psychomotor activity, but there are numerous and pronounced
delusions, mostly of a threatening and persecutory nature; such as, cursing voices, visions of fright-

hallucinations

and

ful and threatening forms, and ideas of poisoning and personal injury. The emotional attitude is usually one of intense anxiety and sadness. The patients are often productive and relate adventurous experiences.

The

other form, which, indeed,
1

may
f.

develop directly from

Aschaffenburg, Allgem. Zeitschr.

Psychiatrie LII, 75.

126

FORMS OF MENTAL DISEASE
first,

The

is characterized by great psychomotor activity. delirium usually develops rapidly with marked hallucinations, incoherent delusions, delirious confusion of

the

thought, sometimes flight of ideas, also an intensely anxious emotional state, together with senseless impulsive movements.
delirium the sleep is greatly disturbed, and there is little appetite; on the other hand, there is usually but slight rise in temperature, and the pulse is not
initial

During the

accelerated.

The

onset

may

be rendered

recognition of the type of delirium at the difficult by the absence of the char-

typhoid symptoms, which may not appear until the delirium is well established. Farrar 1 lays stress upon
acteristic

impaired associative activity, fallacious sense deception, with
developing delusions, disorientation, psychomotor excitement, and anxious affective states. He also calls attention
to certain prodromal symptoms, which may exist from a few hours to many days, as, nervousness, insomnia, and nocturnal restlessness, and believes that cases with a sudden

onset are more uniformly fatal and occur particularly in individuals with a faulty heredity. The initial delirium of smallpox usually develops between the third and fifth days, and is characterized by a short
violent course.

The symptoms

are similar to those observed

in the initial delirium of typhoid, but are characterized

by and violent conduct with a tendency to commit suicide, in which respect one is reminded of the epileptic befogged states. Tremor and convulsions sometimes develop. The symptoms suban even greater clouding
of consciousness, side with the appearance of the eruption, but occasionally extend over into the pustular stage. It rarely happens

that the psychosis passes over into a condition of dementia.
'Farrar, "On Typhoid Psychoses," Medical Reports of the Shepard and Enoch Pratt Hospital, 1903. Vol. 1, No. 1, p. 42.

INFECTION PSYCHOSES

127

The

recognition of the smallpox delirium depends wholly upon the fever, the physical symptoms, and circumstances pointing to this infectious disease.

Another type

smallpox may in which the patients present only vivid hallucinations of sight and hearing, while in other respects they remain well

mental disturbance characteristic of develop between the eruption and pus fever,
of

The oriented, clear in thought, and orderly in conduct. varied visions and voices simply annoy them without causing

much
by

effect.

The course in these initial deliria is frequently characterized
partial remissions during the daytime,
in

which the

patients continue somewhat clouded and do not wholly regain insight into their condition. The duration of the

symptoms

much

rarely extends beyond one week, and usually is shorter. The delirium usually clears with the onset
it

of the fever, but

may

pass over into the characteristic

fever delirium.

The outcome The

is

distinctly unfavorable, as forty to fifty per

cent, of the patients die.

accompanying malaria is distinctly intermittent, either accompanying or replacing the fever. It occurs most frequently in the tertian and quotidian forms,

infection delirium

and

rarely in the quartan. The delirium may appear only in the early stages of the disease, during this time replacing

the fever for a few days.

and

consist of states of

found clouding of
violence.

The symptoms develop suddenly, marked anxious excitement with proconsciousness and a tendency to reckless

All of these symptoms suddenly disappear after a few hours' duration, and are followed by profound sleep, from which the patient awakes with little or no memory of

the attack.

The delirium always responds

readily to the

use of quinine.

128

FORMS OF MENTAL DISEASE
*

The delirium that accompanies acute chorea, when associated with acute polyarthritis and

particularly
endocarditis,

seems to belong to the group of infection psychoses. It is characterized by a clouding of consciousness with a peculiar

dreamy confusion of thought, some hallucinations and deluThese patients apprehend sions and emotional irritability. but continue disoriented and single impressions fairly well, are inattentive and distractible. Their speech is characterized by monotonous disjointed sentences, in which they occasionally weave incidental observations. While they may hear voices calling, see strange visions, and express persecutory or fearful delusions, these ideas are not clear and are never elaborated further. The emotional attitude varies, as at times they are anxious, at others elated, and occasionally show outbursts of passion.
This mental picture is accompanied by a condition of almost constant choreic excitation, in which the characteristic choreic

movements continue

in

both day and night, preventing sleep greatly with nutrition. The duration of the psychosis is from a few days to a few weeks, and not infrequently terminates
fatally.

an exaggerated form and also interfering

Other infectious diseases that may give rise to a delirious state which apparently depends upon a toxaemia, are in2 In the first fluenza, hydrophobia, and certain septic states.
there

apt to be clouding of consciousness, delirious hallucinations, confusion of speech, and anxious excitement.
is

Sometimes there

is

also present paralysis of speech

and
psy-

deglutition, as well as polyneuritic
1

symptoms.
.

The

Mobius, Neural. Beitrage, II, 123, 1894 Zinn, Archiv f Psy. 411, 1896; Krafft-Ebing, Wiener Klin. Rundschau, 1900, 30.
;

XXVIII,

2

Hogyes, Lyssa, Nothnagel's Handbuch der Pathologic u. Therapie,
1897.

V,

5, 88,

INFECTION PSYCHOSES
chosis

129

accompanying hydrophobia
In

is

a delirium in which

hallucinations

patients

may

predominate. septic states the develop a delirium in which there are many

the

hallucinations, clouding of consciousness with disorientation, low and indistinct mumbling, and attempts to grasp at invisible objects.

At times the condition
is

is

one of pronounced

delirious excitement.

a group of cases which seem more properly classified here than elsewhere. It includes those delirious
Finally, there
states that

sometimes accompany furunculosis or follow a slight
illness,

angina, intestinal catarrh, obstinate constipation, etc., may occur in the course of any other type of Some psychosis, which suddenly takes a turn for the worse.
physical
or

would include
other states of

this particular type of delirium

with certain

marked excitement, and denominate them all The delirium seems to arise from a recent active infectious involvement of the cortex, as shown in the pathological anatomy, by an acute destruction of
"

Acute Delirium."

the nerve

cells,

sometimes including

the

fibres,

in ad-

dition to an increase of the glia, and vascular changes with diapedesis of leucocytes and occasionally an escape of the blood corpuscles.

The patients become sleepless, bewildered, and distractible. Numerous hallucinations of sight and hearing appear, and incoherent expansive and persecutory delusions are expressed. They prattle away, sometimes pray, and finally
be resolved into a repetition of a few senseless words and syllables. Emotionally, they may be anxious,
speech

may

elated, or irritable.

The
is

activity

is

greatly increased

and

accompanied by impulsiveness, with pounding, dancing,
yelling, etc.

rapidly.

usually refused and the patients fail Temperature develops; and there appear ecchy-

Food

moses or

fat

embolism, furunculosis, gangrene of the lung,

130

FORMS OF MENTAL DISEASE

severe catarrh of the nose, gangrene of the mouth, sometimes parotitis and retention of urine and feces. In the

vast majority of cases the delirium runs a fatal course in from one to two weeks.

An accurate
The

differentiation of this

form

of psychosis based

alone upon the

symptoms

is

at present almost impossible.

delirious states

which sometimes develop in paresis and

catatonia are recognized only by the previous history of symptoms characteristic of these diseases antedating the

delirium.

Collapse delirium, which

may arise from an

iden-

tical toxic state,

can be distinguished only by the relative
it

the clouding is less profound, the activity less turbulent, while the hallucinations and delusions are more vivid, and in the speech both distractibility
observations that in

and flight of ideas prevail. The treatment of these different infection deliria depends in some measure upon the treatment of the underlying
In view of the toxic origin of the disease a thorough flushing of the body combined with infusion of normal salt solution is excellent practice. One may employ
physical disease.

the prolonged warm bath (see p. 140) for relieving the motor excitement. Sufficient liquid nourishment is always indicated, which nasal tube.

may have

to be administered by stomach or The bowels must be kept open, for which

purpose high rectal injection of normal saline solution may be used twice daily. Furthermore, the mouth should be
cleaned by frequent swabbing.

In case medicinal sedatives

seem

advisable, alcohol and paraldehyde are well recommended, but powerful narcotics and sedatives should be

sedulously avoided. Failing heart action should be supported by the use of caffein, camphor, or ether.

INFECTION PSYCHOSES
POST INFECTION PSYCHOSES

131

0.

These psychoses are in general characterized by a more or less pronounced degree of intellectual and emotional weakness, together with, in

most instances, pronounced delusion

The

formation and a prevailing sad or anxious emotional attitude. postfebrile psychoses described here by no means include
all of

in infectious diseases.

the psychoses appearing after the febrile period The exhaustion psychoses as well as
of

most any other form
this period.

mental disease

may

develop during

The

first

symptoms often, but not always,

appear before the fever wholly subsides. The mildest form of postfebrile infection psychosis is represented by those cases in which after the subsidence of the
fever in a severe attack of infectious disease, the patients

show their former physical and mental energy. They and sluggish, and are very susceptible to fatigue. They cannot collect their thoughts, and find it difficult to read and write, are indifferent, idly lie abed, and let things go as they will. Orientation is undisturbed and there usually are no hallucinations, although transient hallucinations may appear after closing the eyes, when for a few moments they
fail

to

are dull

hear unintelligible sounds, see faint visions, or experience
peculiar bodily sensations which are interpreted by them as grave symptoms. In emotional attitude they are sad and
troubled, sometimes irritable, and occasionally at night they suddenly develop a state of great anxiety. They may at times exhibit a distrust of their surroundings, transitory fear
of poisoning, hypochondriacal ideas,

and even delusions

of

persecution, which

may give rise to aggressive attacks and attempts at suicide. In actions they are inclined to be reserved, sort of stupid, and reticent about their delusions.
Physically, sleep

and appetite are poor and body weight

much

reduced.

132

FORMS OF MENTAL DISEASE

This mild form follows particularly influenza and polyarthritis,

and whooping cough

in children.

seen in tuberculous and choreic cases.

It is occasionally After a duration of

a few weeks to a few months, improvement gradually sets in, provided the underlying physical disease has cleared up.
This syndrome, although suggestive of chronic nervous exhaustion, may be differentiated from it by the fact that
the

symptoms

are

more severe and stubborn, and do not

improve under rest and relaxation.
exhaustion.

Furthermore, there is not the same clear insight that exists in chronic nervous

A

second group of postfebrile infection psychoses

is

char-

by more pronounced symptoms; namely, prominent hallucinations, fantastic delusions, and active excitement with anxiety. When the symptoms first appear, which is always during the febrile period, there is complete disorientation with marked confusion of thought, and very many hallucinations which may involve all of the senses. After the temperature subsides and the symptoms of the initial disease disappear, the patients gradually become somewhat oriented and more composed, but the hallucinations and delusions persist. They still hear threatening voices, see grinning faces looking in at the window, and must get out of the bed and at them. Some one pulls the bedding, the food is not genuine, they are poisoned, no one
acterized

do the right thing for them, etc. Emotionally, are dejected, anxious, and ill-humored. Sometimes, in they outbursts of passion, they attempt suicide and become
is

willing to

violent.

They are apt to be obstinate, quarrelsome, conand resistive. Physically, there is faulty nutrition strained, and insomnia. As the appetite and sleep improve, the hallucinations and delusions disappear. The patients gain insight into their condition, begin to busy themselves, and

POST INFECTION PSYCHOSES
resume
their

133

accustomed conduct, but for some time they show an unusual susceptibility to fatigue, and an absence of the wonted mental and physical energy, together with weakness of memory. A few cases never comcontinue to

and always due some complication. The duration varies from several months to a year. This form follows especially typhoid, smallpox, articular rheumatism, and sometimes
pletely recover. to exhaustion or

A fatal termination is rare,

develops during tuberculosis. In adults, there may be some difficulty in differentiating this condition from melancholia of involution developing

during an attack of some infectious disease. It, however, may be distinguished by the greater prominence of hallucinations, the predominance of delusions of persecution over self-accusations, and the great irritability in contrast to the

anxiety of the melancholiac. It may be differentiated from dementia prcecox by the greater affect and disturbance of

apprehension and orientation at the onset of the disease, and by the absence of negativism and stereotypy; from the depressive phase of manic-depressive insanity by the absence

psychomotor retardation. third and severest form of postfebrile infection psychosis is characterized by a severe delirium which soon passes over into a condition of stupor. In spite of improvement in
of

The

the physical condition the patients continue dull, and incapable of perceiving and elaborating external impressions, and

have poor memory and judgment. Emotionally, they are indifferent, sometimes peevish. They may be quiet or childishly restless.

care for

They lie abed unable to take their food or themselves, and have to be petted and handled like

small children.

and

Physically, they fail markedly in nutrition, occasionally give evidence of severe cerebral disorder,

ashemiplegia, disturbance of speech, and epileptiform attacks.

134

FORMS OF MENTAL DISEASE

The prognosis is dubious, as after an extended course of many months only one-half of the cases recover. The other cases
improve gradually but present as residuals, weakness of will-power, poor judgment, forgetfulness, poverty of thought, and apathy. This form follows chiefly typhoid fever, and sometimes malaria. It may be distinguished from the stupor
of the catatonic state by the absence of negativism, and from the stupor of the manic-depressive by the absence of retardation and the presence of faulty memory.

treatment of all these three types of postfebrile infection psychosis is mostly symptomatic, with very careful

The

nursing, rest in bed, nutritious diet,
Still

and cautious watching.
is

another group of postfebrile infection psychoses

Cerebropathia psychica toxamica," which was first " 1 described by Korssakow Psychosis," (Korssakow's " " Neurocerebrite Toxique"). Polyneuritis Psychosis," It is characterized by a pronounced disturbance of that element of memory which we call impressibility also by disorientation and the physical signs of polyneuritis, associated somethe
,

"

times with a delirious excitement or stupidity.

The symp-

toms

of this form of polyneuritic psychosis are very similar to the alcoholic polyneuritic psychosis (see p. 184), and can be distinguished only by their more prolonged course and the

The duration of the history of the underlying physical state. psychosis extends over many months, in case death does not
and the outcome is rather more favorable than in the alcoholic cases. The treatment is practically the same as
occur,

that outlined in the other forms, with the exception that some attention must be paid to the muscular atrophies,
Korssakow, Gazette russe hebdomadaire clinique, 1889, No. 57 Meyer in Raecke, Archiv f. Psych., 1903, Bd. 37, H. I; Turner, Jour, of Ment. Sci., October, 1903; Miller, Am. Jour. f. Ins., LX, No. 4, 1904;
;

1

Frie

ftnder,

Monatschr.

f.

Psych., VI, 4491

;

Raimann,

idem., XII, 329.

POST INFECTION PSYCHOSES
which demand the use
of electricity

135
after the

and massage

subsidence of the acute neuritic symptoms. There is still another form of postfebrile infection psychosis, different from any of the preceding forms, which is
characterized

by the sudden appearance

of active excite-

ment with clouding

of consciousness, flight of ideas,

and

fantastic expansive delusions, simulating the symptoms of the expansive paretic. Following a few indefinite prodromal

symptoms there appears

first,

usually during the febrile

period, considerable restlessness, then disorientation, distractibility, and hallucinations of sight and hearing, and
finally the

most elaborate grandiose
extensively.

delusions.

The patients

also

fabricate

Emotionally, they are some-

times irritable,

sometimes elated, but always changing from one state to another. There is absolutely no rapidly In addition, the patients are productive and show insight.
a flight of ideas with a tendency to rhyming. The restlessness is so great that they cannot remain in bed. Little food
is

taken, sleep is scanty, and nutrition suffers greatly. This form follows typhoid. In part of the cases the course is rapid and the outcome favorable. After some months the excitedelusions gradually disappear. The patients, continue to be irritable, susceptible to fatigue, and however,

ment and the
upon
ideas
slight

mental application easily develop again
fabrications,

flight of

and delusional
silly

and may show a charis

acteristic

elation

even when convalescence

well

established.

In a considerable number of cases dementia

ensues.

This form

may be

distinguished from paresis

by the

absence of physical signs. The treatment consists mostly of continued rest in bed, prolonged warm baths to alleviate
the excitement, a nutritious diet, and very careful nursing.

II.

EXHAUSTION PSYCHOSES

THE exhaustion psychoses, collapse delirium, amentia, and chronic nervous exhaustion, include those forms of mental disease that seem to arise from excessive exhaustion or insufficient restoration of the

nervous elements in the cerebral
"

is most applicable to those that immediately follow a severe and radical psychoses change of the physical organism, such as that produced by

cortex.

The term

"

exhaustion

acute diseases, excessive loss of blood, and childbirth. But even here one cannot always exclude the possibility of a toxaemia arising from an infectious organism or from the
destruction of tissue.
result in

more accurate knowledge may these forms being grouped elsewhere and asother etiological factors. This occurred in " of acute dementia," which is now classed
of

A

cribed

to

the

case

in the
it

group

post

infection

represents a

phase in

psychoses, except when catatonia or manic-depressive

insanity.

and amentia, though they run a slightly many symptoms in common; namely, a profound disturbance of apprehension and of the coherence of thought, as well as hallucinations, flight of ideas, and psychomotor excitement. Exhaustion arising from more prolonged mental and emotional stress, or extended physical illness, produces the less acute but more chronic
Collapse delirium
different course,

have

psychosis,
thenia).

chronic

nervous

exhaustion

(acquired neuras-

136

EXHAUSTION PSYCHOSES
A.

137

COLLAPSE DELIRIUM

This psychosis
profound

is

characterized
of

by an acute onset with
great

clouding

consciousness,

incoherence

of

thought, dreamy hallucinations, a changeable emotional attitude, and great psychomotor activity, a rapid course, and a
fairly favorable prognosis.

Etiology.

Among
birth
sive
is

Collapse delirium is a rare form of insanity. the exhausting conditions giving rise to it, childthe most prominent; others are loss of blood, exces-

mental

anxiety. tion are

emotional shock, and deprivation with The acute diseases which may lead to this condistrain,

pneumonia and

erysipelas.
is

Oftentimes a fright
acts as

occurring while the patient the exciting cause.

in a

weak condition

Pathological Anatomy. Unfortunately but few cases have been examined pathologically. Alzheimer, 1 in a case which seems to belong to this group, found throughout the
cerebral cortex a fine granular disintegration of the chromatic substance, and without much involvement of the

nucleus or increase of

glia.

Following a few days of insomnia and the patients rapidly become disoriented and restlessness, everything about them seems changed and unnatural.

Symptomatology.

Numerous dreamy

illusions

and

designs on the carpet assume gas light appears like the sun, neighbors pass to and fro, beautiful music is heard, and patients pass through all sorts
of

hallucinations appear; the the form of threatening figures,

dreamy experiences. They become very talkative, the content
1

of speech show-

ing great incoherence with a

flight of ideas,

many

allitera-

Wanderversammlung

d.

suedwest

Neurolog.

u.

Irrenraetze

an

Baden-Baden, 1897.

138

FORMS OF MENTAL DISEASE
rhymes, and repetitions, which

tions,

may

be sung as well
depressive.

as spoken.

Numerous

delusions are expressed which are

incoherent, changeable,

and both exalted and

In

emotional attitude patients are

much

exalted and some-

times erotic

; depression with anxiety, however, may prethe emotional tone. Occasionally there is irritadominate

bility

with exhibitions of passion.

The motor excitement is very pronounced; patients remove their clothing, race about the room, overturn furniThey are both destructive and ture, and pound the door. untidy, and often exhibit the most reckless and impulsive
movements.
a whisper,

They

prattle

away

incessantly, sometimes in

now at the top of their voice, and again gesticuand clapping their hands. The attention cannot be lating attracted and questions are rarely answered. They will not
obey requests, but almost always exhibit a purposeless resistance to everything, even to bathing and dressing.
great insomnia. If the patients Likewise they take sleep at all, it is only for short intervals. but little nourishment, and in many cases require mechaniPhysically.
is

There

The condition of nutrition is wretched, and a marked loss of flesh and physical weakness. The skin is pale and clammy, the temperature usually subnormal, and the pulse weak and irregular. The reflexes are usually
cal feeding.
is

there

exaggerated.

Tremor

is

sometimes present and there

is

a

tendency to acute decubitus. The duration of the disease Course.
of only a

is brief, sometimes few hours or days, and rarely lasting over one to

The return to consciousness is usually sudden, often following a sound sleep. When the patients awaken, the hallucinations and illusions have disappeared; they are
two weeks.
conscious of their surroundings and ask for nourishment. They may continue talkative, perhaps showing a flight of

EXHAUSTION PSYCHOSES
ideas,

139

some

several hours

exaltation, grumbling, and fretful manners for and even days. Brief relapses sometimes occur.
is

As soon
rapidly.

as nourishment

freely taken, the weight increases

Diagnosis.

The

differentiation

from infection delirium

has already been considered (see p. 130). The epileptic befogged states are distinguished by the greater clouding of consciousness, a more uniform emotional tone which is

mostly anxious or ecstatic, and the fact that the activity does not conform to the thought or the emotional expressions.

The

catatonic excitement is recognized

orientation,

and the

characteristic

by the clearer catatonic movements.
can be
dif-

The
tion

delirious excitement of dementia paralytica

by the history of preceding mental deterioraand the presence of characteristic physical signs. The delirious mania of manic-depressive insanity, in the absence
ferentiated only

of a history of previous attacks, can be recognized only by a greater disturbance of apprehension and the very vivid
hallucinosis.

Amentia

is

differentiated

by the longer course
is

and
if

distractibility of the attention.

Prognosis. Recovery from the mental disorder the patients do not die from collapse.

usual

Treatment.
tain nutrition

The important indications are first to mainand next to alleviate the excitement. The
accomplishment of which
it

patients must, therefore, receive a sufficient quantity of
liquid nourishment, in the
is

often necessary to resort to forced feeding by stomach or nasal tube. little alcohol (one to two ounces) added to

A

the milk and egg is extremely valuable. Broths and peptonized meats may be given in small quantities. Where mechanical feeding is contraindicated, because of vomiting or

abrasion and hemorrhage of the mucous membrane, nutrient

enemata can be substituted.

Failing in this one can always

140

FORMS OF MENTAL DISEASE
normal
saline solution,

resort to the hypodermoclysis of

one

to

two pints, with the expectation of securing excellent reimpending
collapse.

sults, especially if there is

The

infu-

sion should be given under low pressure in the back, rump,

or breast.

In the alleviation of the excitement, by far the most efficient remedy is the prolonged warm bath, into which the
patient should be placed at once

and kept there

until the

The bath should be maintained at The all the time. patients may remain in the bath without fear of harm for hours and even days at a time, but usually they become quiet in less than an hour, when they should be returned to bed. As soon as the excitement reappears, they should
excitement subsides.
ninety-five to ninety-eight degrees F.

again be placed in the bath. If the patients exhibit fear in entering the bath and require holding, the bath can do

but

little

good.

In such

cases,

one

may

injection

of hyoscine

hydrobromate,

-^

give a hypodermic to -$ grain, or
first

trional, 15 grains, shortly before the

bath for the

few

become accustomed to the bath they usually like it, and some even fall asleep in it. If the bath is not available and one must resort to hypnotic and sedative drugs, hyoscine hydrobromate -^ to grain and paraldehyde forty-five minims to one drachm may be relied upon for the best results. / One should not be persuaded to overload the system with sedatives in an effort wholly to subdue the excitement in the hope of securing quiet for others. \ Excitement, of itself, is by no means the most serious symptom. It is sufficient if you succeed in procuring even a few hours' sleep and prevent the patients from wholly exhausting themselves. Prolonged warm baths
times.

As soon

as the patients

^

properly applied usually render unnecessary the use of If the patients collapse, hot coffee by mouth or sedatives.

EXHAUSTION PSYCHOSES

141

rectum, strychnia, dignitalis, or hypodermic injections of

camphorated
sufficient

oil

are indicated.

It is best that the patients

be isolated in a quiet place, with attendance to control them at all times. Constant

attendance must be enforced in order to prevent injuries, and this must be observed until convalescence is well established.

Mechanical restraint should not be employed; a

padded bed or room is preferable. During convalescence the same indications obtain here as in convalescence from any acute disease careful feeding, graduated exercise, and freedom from all forms of excitement. Finally, one must
:

be assured of complete recovery before the patients are permitted to resume their usual occupation or responsibilities. A good index of this is found in the weight, which should
always return to normal.
B.

ACUTE CONFUSIONAL INSANITY (AMENTIA)

is characterized by the numerous illusions and hallucinations, rapid appearance of clouding of consciousness, and motor excitement, with a

This form of exhaustion psychosis

duration of two
Etiology.

to three

months.
of exhaustion giving rise to

The conditions

amentia #re chiefly childbirth, also acute illnesses, excessive loss of blood, excessive mental strain, and night watching.

An emotional shock may be the final exciting factor. Women
are

more frequently

affected than

men.

Cases of amentia

represent about one-half to one per cent, of the admissions to
hospitals.

Symptomatology.
less,

At

first

the patients are anxious, rest-

and

forgetful,

sometimes complaining of numbness and

confusion in the head, and inability to gather their thoughts or concentrate their attention. In the course of a few days
disorientation appears; the surroundings

seem changed, and

142

FORMS OF MENTAL DISEASE
Hallucinations of the dif-

they do not recognize relatives.
ferent senses appear.

They see strange faces and hear birds are flying about, lions are roaring, strange voices, poisonous powder is thrown at them, and they are threatened
and cursed by form the basis
strangers.
for

The numerous

hallucinations

depressive delusions, which are dreamy, incoherent, contradictory, and often repeated. Their children are dead, the home is lost, they are to be

many

hung, are under the influence of some magnetic power which draws them about, and in the end will consume them. In

a few cases the delusions are expansive; they then believe themselves exalted to some high position, possessed of great
wealth, or they have journeyed around the world. will convene Congress, and send an army to Cuba.

They They

sometimes fabricate extensively.

by the surroundings and the endeavor to grasp what transpires. It is usually patients
attention is attracted
possible, also, to direct the train of

The

before them,

by movements and

thought by objects held gestures; but they under-

stand readily only the simplest occurrences. Some patients claim that everything is changed, things are not genuine,
the chairs and windows are not the same to-day as yesterday, the thermometer is not correct, the clock is not right,

and the papers are

Often the patients incorrectly dated. appreciate this inability to understand things, and complain " that they cannot "think right or that some one "has made

them

crazy."
is

disturbance of the train of thought. The patients are unable to complete one idea before others interrupt, producing a flight of ideas.

There

marked

Words and sounds

caught up from the surroundings find a place in their expression, though not necessarily influencing or directing the
train of thought.

The speech

is

sometimes made up of

EXHAUSTION PSYCHOSES
single, incoherent,

143

and disjointed words and phrases. Occasound associations and rhymes are heard. In spite sionally of distractibility and flight of ideas, one occasionally finds
the patients holding to single indefinite ideas, usually of persecution. The consciousness is much clouded. The persistence of clouded consciousness, with difficulty in arrang-

ing the impressions and ideas, is a characteristic and striking feature during the intervals when the patients are quiet and

present a normal emotional attitude. The emotional attitude varies considerably, sometimes with
prevailing happiness, but more often with depression. Alternations of the attitude are characteristic; for short periods

the patients may be elated, and hilarious, with perhaps some sexual excitement, when they suddenly become excited and irritable, or they may even be dull and stupid.

In the psychomotor

field there is

a marked pressure of

They move about restlessly, crawl in and out of activity. bed, destroy clothing, pound and beat, but the movements are not very quick, are performed without display of much energy, and are planless. The motor excitement is distinctly intermittent, there being intervals of complete quiet.

The sleep is much disturbed, the appetite is and sometimes there is complete refusal of food. The poor, body weight falls, but the condition of nutrition is better than in collapse delirium. The deep reflexes are increased, the pulse slow, and the temperature subnormal. Course. The height of the disease is usually reached within two weeks, during which time there may have been
Physically.

remissions of a few hours or even a day with clear consciousFrom ness, insight, and disappearance of hallucinations.
this time the symptoms present characteristic fluctuations. The more active symptoms may disappear, and the patients become more coherent in speech, when again they develop

144
excitement.

FORMS OF MENTAL DISEASE

Genuine improvement develops gradually. have become clear, long conversations or Even letter-writing tend to create confusion. In the lighter cases, which are the more numerous, even after the patients have
after they

become quite

clear,

the emotional attitude

may show

a

slightly elated or depressed condition, as seen in hyperactivity and garrulity, or distrust, anxiety, and irritability.

The

from three to four months. In the severer cases, lasting some months, even when the patients have become clear, a few hallucinations may persist for a short time, and occasionally indefinite and transitory exentire course
is

pansive or depressive delusions are expressed. The patients may appear unnatural and irritable and show outbursts of
passion.

Even

after all the

symptoms

of the disease

have

disappeared, the patients are very apt to show increased susceptibility to fatigue, while for many months emotional

shocks or injuries are prone to create relapses.
rises rapidly

The weight

during convalescence.

Diagnosis.
is

The manic form

of manic-depressive insan-

ity distinguished from amentia by the fact that there is less disturbance of apprehension than of the psychomotor sphere; in the manic state, in spite of great motor excite-

ment, the patients usually give evidence of at least a partial comprehension of the environment. Again in amentia the

movements are
are
still

slower, more planless, and less precipitous, in quiet intervals, when there is no activity, the patients and,

hazy and confused.
is

The condition

of catatonic

excitement

distinguished by the fact that the catatonic in the midst of the greatest excitement are usually patients able to comprehend their surroundings, to reckon time
correctly, to recognize persons,

and to record some passing

events. The amentia patients even during quiet are somewhat disoriented and fail to recall passing events. Further-

EXHAUSTION PSYCHOSES

145

more, the characteristic catatonic features are absent. To be sure, catalepsy and automatism may be present, but
genuine negativism, verbigeration, stereotypy, mutism, and

mannerism are absent. Death rarely occurs except as the Prognosis.
suicide, of

result of

collapse during the intense excitement at the or precarious physical conditions; as, heart failure, onset,
sepsis,

and

phthisis.

The

patients almost

always fully

recover their mental health.

Treatment.

The

indications for treatment are identical

with those in collapse delirium; namely, maintenance of nutrition and the alleviation of the excitement (see p. 140).

On

account of the great tendency to relapse, one should be extremely careful about allowing the patients to enter an

environment in which they might be subjected to an emotional shock. For this same reason, one cannot resist too
long the entreaties of the patients and their relatives that they be allowed to enter their accustomed life, before they

have regained their normal weight, the menses have reappeared, and the emotional attitude has become wholly
stable.

a.

ACQUIRED NEURASTHENIA

CHRONIC NERVOUS EXHAUSTION

ACQUIRED neurasthenia
power

is

characterized

by a diminished
to fatigue,

of attention, distractibility, defective

mental application,

difficulty of thinking, an increased susceptibility increased emotional irritability, and a great variety

of physical

symptoms, mostly subjective, including hypochondriasis. Acquired neurasthenia must be clearly distinguished from
the psychopathic states or congenital neurasthenia (see No doubt there are many transitional states between p. 155)
.

the two diseases, and especially where both defective heredThe difference ity and exhaustion are prominent factors.

symptoms, their course and outcome, in individuals free from hereditary taints, it seems, is sufficiently distinctive to justify the restricted use of the term acquired neurasthenia. The real nature of the disease has been most Etiology.
in the
logically pointed out

kind of chronic intoxication resulting

by Mobius, who claims that there is a from the effects of

exhaustion upon nervous tissue, corresponding in a measure to the intoxication resulting from the prolonged excessive
use of alcohol.
offers

This view, certainly,
conception
of

is

a

clearer

the

disease

helpful because it and aids in

distinguishing between those cases which simply involve an accumulation of the effects of fatigue and those in which the morbid hereditary and inherently impaired powers of resistance

play the essential role (congenital neurasthenia).
relaxation

The
with

rapid, irregular,

little

and extravagant manner of living, and lack of sufficient and wholesome
146

ACQUIRED NEURASTHENIA

147

sleep in individuals actively engaged in business or taxed with the responsibilities of the household, is distinctively
characteristic
regions,

of the

American people in the temperate

and accounts

in our nation.

for the great prevalence of this disease Besides excessive mental application, the
is

worry attendant upon responsibility

an important

factor.

the other hand, prolonged and excessive physical exertion is at times undoubtedly an important factor in producing neurasthenia, particularly excessive bodily exercise, as is occasionally seen in sports, such as golf, rowing, basket But of especial importance are our faulty methball, etc.

On

nourishment.

ods of living, with insufficient relaxation and improper Moreover, considerable depends upon the

individual powers of resistance. This is particularly applicable to that considerable group of individuals, who always feel unequal to the demands made upon them and find

themselves quickly and completely exhausted upon any strenuous effort.

Of the men, naturally those who are more talented, better educated, and more active, are the individuals who most often suffer from this disease. Indeed, it is a fact
worthy of note that great capacity for work is frequently accompanied by greater susceptibility to fatigue. Women, because of their weaker powers of resistance and their greater emotional irritability, are more susceptible than men, particularly the

The

disease

overburdened mothers, teachers, and nurses. may appear at all ages, but is most often met

between the ages of twenty-five and forty-five, the period of life during which the greatest mental strain occurs. At an
earlier

age it is seen in ambitious students who apply themselves too closely to studies without relaxation. Occasionally

symptoms, which

differ in

no respect from those described

here, develop after emotional shocks

and acute

illnesses,

148

FORMS OF MENTAL DISEASE
and operations.

especially influenza, childbirth, loss of blood,

The

"

nervous weakness"
It is doubtful

cence from severe illness
haustion.
fright.

is

if

which appears during convalesonly in part due to simple exthe disease ever develops after a

Symptomatology.

Prolonged

work

produces

and with

it difficulty

of further application.

Up

fatigue to a certain

which may be considered as a safeguard against overwork, may be overcome by an increased exertion of will power, which in long and fatiguing work gives rise to
degree, this fatigue,

" a feeling of increased effort." Associated with this there soon develops a characteristic feeling of disinclination and

then a fagging of the
of overexertion
is

will,

and when

relieved.

danger While the increased exertion of

this appears the

the will can for a time balance the effects of fatigue through an increased expenditure of power, the effects of fatigue
ultimately gain the upper hand and force one to cease work. The first indications of exhaustion are when, under certain conditions, the increased exertion of will continues for some time in spite of the uncomfortable feeling of fatigue.

This

what happens when work is performed under intense emotional excitement. The signs of fatigue, which call for relaxation, either do not appear or are overwhelmed, and work is prolonged beyond a permissible degree. This in time leads, on the one hand, to an exhaustion of the available supply of strength, which recuperates only very slowly, and is manifested by a sort of prolonged weariness, which persists after relaxation and is still present to some extent when work is again undertaken. It also involves an increased susceptibility to fatigue and a more rapid diminution of the
is

capacity for work. On the other hand, under such circumstances, the increased exertion of the will also persists and
brings with
it

an increased emotional

irritability.

ACQUIRED NEURASTHENIA

149

Unfortunately, there are as yet no experiments on the But we know effect of prolonged overexertion on the mind.

from long experience,

that,, first of all,

the ability

to

con-

tinuously exert the attention fails. The patient is easily distracted by little things and is inattentive. He is no longer able to think clearly and sharply, and requires much

more time
forgetful of

for his

accustomed work.

He
is

is

also apt to be

names and

figures, so that the

same work has to

be done over several times before he

sure of his results.

His susceptibility to fatigue is greatly increased, and his work is carried out only with constantly increasing difficulty,
requiring greater exertion

and more frequent

rests.

As the
he
is

result of this difficulty of work, the patient also loses the

wonted pleasure

in his occupation.

He

finds that

compelled to force himself to the work which he previously performed with ease and pleasure. He, furthermore, shrinks from new undertakings because of obstacles which

appear unsurmountable.

Under the
attitude also

influence of these conditions, the emotional

becomes changed.

The

patients

become

easily

flustered, are ill-humored, unreasonable, peevish, faultfinding,

and impetuous. Customary amusements fail to please,^ and they become discontented with their occupation.
irritable,

Trifling affairs, like the

misconduct of a

child,

inconven-

iences at work, which normally would pass unnoticed, disturb them for hours and even days, and may lead to impulsive

outbursts, which they later regret.

patients have not only a keen insight into these defects, but also a tendency to exaggerate their symptoms.

The

They

assert that the

memory

is

becoming profoundly
is

af-

fected, and that the judgment

failing.

The

physical

symptoms

are even

increasing their

more strongly exaggerated, which aids in misery. The excessive anxiety about their

150

FORMS OF MENTAL DISEASE
of

condition

health leads to

hypochondriasis, in

which there

is

a characteristic symptom, a tendency to pay undue

attention to any trifling symptoms that may be present. They believe that they are suffering from some incurable
disease,

and

especially the one

most dreaded.

There

may

be some genuine disorder, but the real symptoms are greatly enhanced by the attention habitually paid to them. Canker
considered infallible evidence of syphilis, a cloudy urine indicates Bright's disease, and a cough means consumption. In the beginning these fears may not be conis

in the

mouth

sidered in a very serious light, but when they interfere with the livelihood of the patients they may lead to such feelings of despair that the patients no longer hope for recovery,

make their wills, and not infrequently attempt suicide. The appreciation of their incapacity creates a feeling
of reserve, timidity,

and a lack

of self-confidence.

They

cannot trust themselves in public and fear fainting upon the slightest exertion. Associated with the loss of willpower, there should also be mentioned the tendency to

compulsive thoughts and impulsive acts, which sometimes explain the suicidal attempts. Here are included the various phobias, which are fully described in the constitutional psychopathic states. In the strife to overcome impulsive
ideas, the patients often reach

an emotional

crisis of

short

and moaning, and even attempts are more apt to follow continued
longed
visits or

duration, with restlessness, wringing of the hands, crying at suicide. These states
excitations, such as pro-

unusual noisiness.

Physical symptoms. feature of the psychosis.

These form a very characteristic Among the most important symp-

toms are headache, insomnia, general muscular weakness, parsesthesias, cardiac and gastro-intestinal disturbances. Cephalalgia, which appears early, may be expressed as a

ACQUIRED NEURASTHENIA

151

headache, a feeling of numbness or a pressure in the head, which interferes with work. This is usually situated over
the eyes or in the occiput, and increases with exertion until it becomes unendurable. It is more prominent in the morning

and passes

oft

feeling of pressure, as

Sometimes there is a during the day. if the head were held in a vice or by

a constricting band. It may be associated with vertigo, dimness of vision, roaring in the ears, or painful pressure
points in the scalp.

Insomnia
onset.

is

usually an aggravating

symptom from

the

upon

of sleep, obtained either immediately or in the early morning, after hours of restless retiring,

The few hours

tossing, are unrefreshing

and disturbed by dreams.

In some

cases, there is an unnatural drowsiness which causes the patients to fall to sleep at all times and particularly after

some

exertion.

General muscular weakness

is

always in

evidence; patients are always languid, and tire easily walking or from slight muscular effort.

upon

Both the

superficial

and deep

reflexes

may

be increased.

Rhythmic twitchings are occasionally noticed, particularly twitching of individual muscles and especially those of the
Moderate stuttering is sometimes complained of. There is slight tremor of the eyelids and hands, but usually
eye.

a marked

tremor of the tongue. Subjective sensations, variously located, are prominent, such as parsesthesias or feelings of formication in the trunk and limbs, also darting
fibrillary

pains and burning sensations. The patients are usually alarmed by various cardiac sensations; such as a gnawing or burning sensation, palpitation

and precordial pain and pulsations in different parts of the body. The pulse rate varies considerably and is easily influenced by work or emotional excitement. Associated
with the cardiac disturbances or occurring independently,

152

FORMS OF MENTAL DISEASE

there

may be vasomotor

ized sweating,

and anorexia is frequent, but the nervous dyspepsia, gastric and intestinal, is by far the most prominent digestive disorder. When the stomach is
variable

and The appetite is

disorders; as cold extremities, localblushing or abnormal dryness of the skin.

empty, there

is

usually present a gnawing sensation which

is

quickly relieved by eating. Gastric fermentation, probably due in part to deficiency of the digestive fluids, especially
hydrochloric acid, causes distention of the stomach, accompanied with discomfort and pain. Extending into the
intestines, the fermentation gives rise to

colicky pains, the latter

borborygmus and of which may be severe enough to

simulate genuine

digestion is usually not impaired sufficiently to create disturbances of nutrition, but in severe cases it may even cause cachexia and anaemia. The
colic.

The

usually constipated and the tongue coated. Diarrhoeas are apt to appear for short periods, and may be persistent for a considerable time.

bowels are

In the sexual

life

there

is

more often a
is

loss of sexual desire,

but in a few cases there
gence, although at the

a tendency to excessive indulof

same time patients may complain
is

impotence. In those cases in which there

frequent recurrence, the patients tend to become chronic invalids of a most distressing type. They go the round of physicians, pass from one sani-

tarium to another, taking

all kinds of drugs. Mentally, into a state of lethargy in which all thought centers they pass about their own misery. All attempts at business are aban-

doned, and the cares of the household are renounced. They betake themselves to the seclusion of a charitable institution

with

its

demand

freedom from annoyances, or if they remain at home, the utmost consideration for every whim. They

have no thought for the maintenance of the family or ap-

ACQUIRED NEURASTHENIA
preciation of the burden which they create. demand for sympathy leads to prevarications

153

The and

increasing to various

assumed contortions,

in order to assure the physicians or

friends that they are in a critical condition.

The

daily
!

My God, doctor, I am dying greeting from one patient was, Just feel of my abdomen. Have you no compassion for a " A female patient remained in bed for years, dying man?
and when received at the hospital from the hands of a tender-hearted mother, had not had her hair combed in two years, and one of her toe nails had grown to the
length of five
inches.
It is this
class of patients

"

who

eventually become habitues of morphin, cocain, chloral, antipyrin, and other drugs.
It may, is gradual. an acute illness, especially however, develop rapidly, following influenza and also childbirth. There is a great variation in

Course.

The onset

of the disease

the prominence of the symptoms.

A

daily

improvement

toward evening

is

characteristic.

Under

stress of circum-

stances, the patients are usually able to pull themselves to-

gether for a special occasion, but the following day witnesses an exacerbation of the symptoms. The course is often
protracted and the convalescence gradual. The differentiation of neurasthenia Diagnosis.
other forms of mental disease
is

from

of the greatest importance

because of

In the

bearing upon the prognosis and treatment. place it is necessary to exclude organic disease of the internal organs. The diagnosis of neurasthenia should
its
first

rather be reached

by a process

of exclusion, after a

most

thorough physical examination. The psychoses most apt to be confounded with neurasthenia are dementia paralytica, dementia prsecox, and melancholia of involution. The difficulties in dementia paralytica arise

only in the

first

stages of the disease.

Signs of

154

FORMS OF MENTAL DISEASE

nervousness without definite cause in a

man

of healthy con-

stitution, appearing for the first time in middle life, should at In neurasleast arouse suspicion of dementia paralytica.

thenia the alleged memory defect varies from day to day, is easily corrected upon effort, and does not show the defective

time element which
ory in the paretic.

is

so characteristic of the defective

mem-

Neurastheniacs complain of mental im-

pairment, but are able to amend errors in writing and speech, while the real mental defect in the paretic is unrecogrecognized, its extent is not appreciated. The defect, therefore, in the work of a neurastheniac is quantiThe symptative, while that in the paretic is qualitative.
nized, or,
if

toms

of the neurastheniac ameliorate as the

day advances, so

that the evening finds
paretic usually

him

at his best ; on the other hand, the

awakens refreshed, and more capable, but more during the day. Again, the neurastheniac has fatigues a keen insight into his condition, and tends to exaggerate his symptoms, but the paretic has little or no insight, or, if present,

he rather minimizes than exaggerates his symptoms.
of the neurastheniac are mostly

The sensory disturbances

The subjective, while those of the paretic are objective. of the characteristic physical signs of paresis should presence
leave no doubt; such as, Argyl Robertson pupil, increased myotatic irritability, ataxia in speech and gait, tremor of

the facial muscles and of the tongue, epileptiform or apoplectiform attacks, etc.

The depressive phases of the other psychoses, especially dementia prcecox and melancholia, are distinguished with
difficulty, particularly where these psychoses follow some acute disease, or appear in neuropathic individuals who have succumbed in the struggle with more favorably endowed associates. While the neurastheniac is ill-humored and

irritable

because he appreciates that his mental ability

is

ACQUIRED NEURASTHENIA

155

impaired, his emotional attitude becomes happier just as soon as some external excitement or a jolly company allows him
to forget his troubles, or as soon as he is relieved of the responsibilities of his occupation, and can secure the benefit of
rest

and relaxation.

In the despondency of other psychoses

there develops a feeling of anxiety and sadness without any good reason, which, under the influence of distraction, is

not only not alleviated but may even be intensified. The diminution in the power of comprehension and the ill-humor
at the onset of dementia prsecox is recognized especially by the dulness of the patient, his indifference to the future,

and sometimes

also

by the

senselessness of his hypochon-

driacal complaints.

external causes of exhaustion are comparatively insignificant one naturally suspects that there is at the bottom a constitutional nervous weakness, which demands not
rest

Where the

and relaxation but

exercise

very sharp distinctions cannot be

and occupation. While drawn between these states,

yet there are some symptoms in congenital neurasthenia which are rarely, or to only an insignificant degree, found in simple neurasthenia; namely, the great susceptibility of the individual symptoms to mental suggestion, especially
the abrupt fluctuations of the emotional attitude, the anxious states, and the lack of strength.

The prognosis in simple nervous exhaustion as favorable, but it depends upon the extent to regarded which the exciting causes can be removed, as well as upon the
Prognosis.
is

individual's powers of resistance.

Under proper treatment

most patients greatly improve, but the probability of a return of the disease sooner or later becomes much greater, if the patient must enter his old environment and undertake the same responsibilities that lead to the first breakdown. The more frequent the recurrence of the

156

FORMS OF MENTAL DISEASE
is

disease, the less liable

the patient ever to regain his

former health.

Where possible, it is the duty of the family physician to bear in mind prophylaxis. Individuals who are handicapped by a defective heritage must be well guarded during their development, with due attention to moral and physical hygiene. Later, when it becomes necessary to enter actively into the severer duties of life, the limitation of mental application and physical exertion, together with the avoidance of worriment and anxiety, must be constantly
Treatment.

kept in mind. In the treatment of the disease after
the individuality of the physician
is

its

development,

of

prime importance;
It
lift

he must recognize and

utilize his

power

of influence over the

patient in addition to various therapeutical agencies. requires confidence in order to inspire the patient and to

him from

morbid anxiety and depression. Isolation with a changed routine of life demands immediate attention. In the lighter cases a trip to the mountains or a sea voyage to relieve the asthenic condition, or where this is impracticable, removal from the customary surroundings into a quiet, restful, but attractive place, will accomplish the same
his
result.

Next, insomnia must be combated. Enforced rest in bed with change of environment, removal of cares and relaxation, and the establishment of a fixed routine usually relieve the

one should not have to employ sedatives until the patient has had a chance to react to the new method of life. Before resorting to the use of drugs,
sleeplessness.
rate,

At any

the simple hypnotic measures should be exhausted; such as, warm liquid nourishment upon retiring, a hot bath, gentle

massage, etc. If it seems necessary to resort to drugs, then employ the triple bromides in five-grain doses repeated every

ACQUIRED NEURASTHENIA
half hour for five doses
if

157

necessary, administered

on

alter-

nate nights with trional, veronal, or somnos.
serviceable

Hydriatics are of great service in this disease, the most methods being the cold ablutions, the spray, the

simple douche, and the dripping sheet. In the last method, which may be carried out at home, after a cold ablution,
eighty-five to seventy-five degrees, the patient standing in

or on a dry surface, with a cold towel about the head, a linen sheet dipped into water seventy-five to fiftyfive degrees, is wound dripping about the patient, the nurse

warm water,

same time applying friction until a thorough reaction takes place. The douche, as carried out at bath institutions, is of great value.
at the

In the more severe cases, the secret of successful treatment lies in a well-regulated routine suited somewhat to the tastes
of the individuals, of sleep,

but requiring of all a definite amount nourishment, mental and physical exercise, alter-

nated with rest and relaxation, together with baths and outof-door life. All of this may be carried out under the supervision of a physician who is willing to spend time and thought in attending to the details. The relative amount of exercise

and forced rest must vary in individual cases. The anaemic and debilitated who have been exhausted by long suffering or the prolonged care of invalids, together with anxiety and worriment, require forced rest for a few weeks with a full nutritious diet, massage, and passive movements. Others, from the beginning, need graduated daily exercise, which must be purposeful and suited somewhat to the tastes. The diet, also, must depend upon the condition of the nutri-

Where indigestion or constipation exists, the usual means should be used to counteract these conditions, always giving preference to physical agencies. Electricity and
tion.

massage are of value, but only secondary to the above

158

FORMS OF MENTAL DISEASE
Sometimes
local treatment is called for in cor-

methods.

recting uterine troubles, errors of optical refraction, or in removing nasal obstructions.
Finally, the patient should not

be considered suitable for

discharge until
relapse.

you have placed her beyond the danger of This involves on her part a thorough understand-

ing of the conditions leading to her breakdown, an inculcation of the correct principles of living

and an appreciation

of her

own

limitations.

and requires and working Such training

should be established early, and throughout the period of treatment no opportunity should be lost in impressing these ideas upon her mind.

III.

INTOXICATION PSYCHOSES

intoxication psychoses is here used in a narrow sense to include all psychoses arising from toxic substances

THE term

taken into the body.

They

are divided into acute

and

chronic

intoxications,

according to the length of the time during which the toxic
substances have been ingested.
1.

ACUTE INTOXICATIONS.
common by

The acute

intoxications are characterized in

a delirious state of short duration, with pronounced psychosensory disturbance, dreamy fantastic delusions, pleasurable emotional attitude, often with conditions of ecstasy,

and without much motor excitement. The number of toxic substances, including ptomaines, which might be mentioned here is large. The transitory character and the infrequency of the toxic deliria make them of little importance to the clinician. They are, howof great scientific value to investigators, who are able to study pathologically and psychologically the effects
ever,

of the different toxic substances.

Some

of

them which

are characterized

mentioned here.
form
is

by peculiar mental symptoms will be The mental state produced by chlorohallucinations of sight only. In are hallucinations of sight in appears yellow; hasheesh delirium is

characterized

by

santonin poisoning there

which everything
characterized

by disturbance of the taste and muscle senses. Hasheesh and opium smoking produce a complacent feeling of well-being, and of a dreamy, pleasurable existence.
159

160

FORMS OF MENTAL DISEASE
carbonic acid

The

narcosis

is

characterized

by

its

short

duration and the presence of pronounced sexual hallucinaIn the toxic condition produced by atropin there is a severe disturbance of apprehension, with isolated hallutions.

marked confusion of thought, elated emotional The course is attitude, and active motor excitement. either fatal or the psychosis clears very quickly with no
cinations,

recollection of the events.

The duration

of all these conditions is short,

from a

The prognosis dethe severity of the intoxication. In pends entirely upon diagnosis one must rely in great measure upon the knowlfew hours to a few days at the most.
edge of the circumstances and upon the physical signs. The treatment is limited to the employment of means to
rid the

body

of the toxic substance,

and the application of

special antidotes.

The psychosis produced by lead poisoning, encephalopathia saturninia, is more frequent and differs from the
above delirious states by its longer duration, characteristic nervous symptoms, and poorer prognosis. The physical symptoms usually precede the mental disturbance; that is,
wrist drop, peroneal paralysis, tremor, pains in the limbs, and sometimes colic. The immediate prodromes are restlessness

and headache.

The onset

of the delirium

may be

acute or subacute.

and

There are many hallucinations of sight hearing, great psychomotor disturbance, many delusions with great fear, and complete clouding of consciousness.
incoherent, and in the height of the delirium there are frequent reckless impulsive movements.
is

The speech
is

There
is

complete insomnia, and very little nourishment taken. The active excitement is followed by a condi-

tion of stupor or coma, sometimes antedated

by stupor with

excitement.

INTOXICATION PSYCHOSES

161

Epileptiform convulsions may also appear, and amblyopia is frequent. The convalescence is gradual, extending over several weeks. Some cases terminate fatally in coma. While most of the patients recover, there are many

who, upon regaining clear consciousness, present a degree of mental enfeeblement in which simple apathy is a prominent feature. A few present progressive muscular atrophy, simulating dementia paralytica. The whole duration of the psychosis in favorable cases is from a few weeks to three
months.

2.

CHRONIC INTOXICATION
toxic substances

to disturbances of the mind, those best

whose continued use leads known and of most Almost clinical value are alcohol, morphin, and cocain. all nations, according to anthropological data, have had a
the

OF

many

drug whose habitual use has been a source of danger to its It is a striking fact that these substances have people.
always been used first for medical purposes, and later continued for their exhilarating and alleged supportive effect.
A. ALCOHOLISM

The acute

intoxication of alcohol

is

described here rather
its

than under the acute intoxications, because of association with chronic alcoholism.
Acute alcoholic intoxication produces at
tion of the
ternal
first

close

a diminu-

and elaboration of exand an acceleration in the release impressions, of voluntary impulses. The perception of simple sensory An attempt is difficult, sluggish, and uncertain. impressions to solve a simple problem shows a distinct diminution in
power
of apprehension
intellectual power.

In speech one can discern that the association of ideas

most

closely related to the

prominent, such as the use of

motor elements of speech is compound words and rhymes.
is

The

release of

motor impulses

much

accelerated so that

those expressions find utterance most readily that are most familiar. The choice between two movements is precipitous,
frequently incorrect, and sometimes already executed before the proper direction is determined upon. Later, or fol162

ACUTE ALCOHOLISM

163

lowing larger doses, the psychomotor activity is displaced by paralysis, the rapidity and extent of the paralysis depending

both upon the amount taken and the susceptibility of the individual. The muscular strength, at first slightly increased,
is

soon

much

diminished.

work.

influence the capacity for good mental are not easily gathered, rendering the Thoughts solution of complicated problems very difficult. This increases

Even small doses

with the amount taken.

A

thoroughly intoxi-

cated
or

man is unable to comprehend what is said to him what goes on about him, cannot maintain his attention He has no conception of or direct the train of thought. the significance or the bearing of his actions. The internal association of the train of thought is very much disturbed, as indicated by the tendency to the repetition of

phrases and the use of commonplace remarks, also in the fondness for quoting obscene rhymes and in the use of jargon. Finally apprehension may be so far lost that he

becomes insensible and unconscious.
the intoxicated state
is

Memory

of events of

very meagre. In the psychomotor field, at first, there is a light grade of overactivity, with the disappearance of the usual restraints which regulate the actions of our daily lives. He
is

and jolly, speaks and acts without reThe ready release straint, and even becomes reckless. of motor impulses promotes the feeling of increased muscular strength. Later the motor excitation increases;
active, gay, free

the facial expression loses its character, each action is exaggerated; the voice is louder, and the smile broadens

He becomes profane, grumbles, and growls. and passionate, and a single word or a trifling hasty accident suffices to start a quarrel or to lead to an assault.
into laughter.

He

is

Finally the excitation, as the disturbance of apprehension

164

FORMS OF MENTAL DISEASE
by

increases, is replaced

profound disturbance of

and there is a speech, a staggering gait, and even
signs of paralysis,

complete motor paralysis. The emotions at first give

way

to a feeling of well-being.

There

a certain degree of exhilaration, and freedom from care. He becomes light-hearted and happy. Later
is

irritability appears.
is

Higher moral feelings are lost. He shameless, and because of the increased sexual excitaof the intoxication
It

bility is often led to filthy excesses.

The duration
the individual.

depends much upon

though

ill

usually disappears quite rapidly, aleffects may be observed for twenty-four to thirty-

six hours later: headache, lassitude, nausea,

and anorexia.

Fatigue predisposes to rapid appearance of paralytic signs, even without the intervention of the period of excitation.
Individuals

who

are rendered sluggish

also to be quarrelsome, aggressive,
cruel.

and sleepy are apt mischievous, and even

As the result of experimental investigations of acute intoxication in test animals, Nissl has demonstrated a profound change in the cortical neurones, seen in the destruction of

many

irregular amalgamation of the Nissl granules, the diminution in size and irregularity
cells,

in the fading

and the

of the nucleus,

disappear.
cells.

whose membrane and nucleolus may finally Dehio has observed similar changes in Purkinje

CHRONIC ALCOHOLISM

CHRONIC alcoholic intoxication depends upon a chronic degenerative process in the central nervous system, and is characterized by a gradually progressive dementia, with diminished capacity for work, faulty judgment, defective memory,

moral deterioration, occasional delusions, infrequent halluci-

and various nervous symptoms. Defective heredity is an important etioEtiology. logical factor, and is manifested by a diminished power of resistance in the individual. Some observers have renations,

ported as high as eighty per cent, of cases with defective heredity, in at least one-half of whom the father had been a
chronic drinker.

two per

Head injury, according to Moli, in twentycent, of the cases, has been regarded as a factor
Male alcoholics

in producing lessened resistance to alcohol.

greatly predominate. At Heidelberg only six per cent, were women. Hirschl, in Vienna, found among the male insane thirty per cent, alcoholics and among the women only four per cent, alcoholics. Alcoholism is more prevalent among those who come in contact with it, especially the bartenders, liquor dealers, brewers, and waiters. The extensive use of alcoholic drinks by many classes of society and the laxness
of public sentiment in regard to it should also be regarded as etiological factors. Furthermore, the ignorance of most

people as to its proven deleterious effects is in a measure an important element. There are thousands upon thousands

who

daily take a little beer, wine, or liquor because they are

does them good," and strengthens them. In the brain, in advanced cases, Pathological Anatomy. there is regularly more or less chronic leptomeningitis and

convinced that

"

it

pachymeningitis with or without hsematoma. The cerebrum is below normal in weight, its convolutions more or less
165

166

FORMS OF MENTAL DISEASE
its

shrunken, and

ventricles dilated, the

ependyma

of

which

in rare instances is granular.

The

larger vessels at the base

and

in the fissures present arteriosclerotic patches or atheis

roma, but the most characteristic lesion

mostly localized, of the small terminal cortex and other parts of the brain. The cortical neurones
present a gradual
of Nissl."
sclerosis,

the endarteritis, arteries of the

called the

"

chronic

change

Nissl, in his experimental research with chronic alcoholism, in test animals, found a moderate thickening of

the pia, especially at the base, destruction of many of the cortical neurones, with an increase of neuroglia, and besides
these other extensive characteristic cortical changes, the meaning of which is still unknown. Alterations in the internal

organs

are

equally

prominent;

namely,

chronic

gastritis, cirrhosis of the liver, chronic nephritis, fatty infiltration of the myocardium, and chronic endocarditis with

greater or less degree of general arteriosclerosis.

There is a gradual and progressive Symptomatology. enfeeblement of the intellectual faculties. The capacity for

work

is first

to suffer.

The power

becomes difficult gradually and the susceptibility to fatigue increases.
fails, it
.

mental application to maintain the attention,
of

New and
is

unac-

customed work requires unusual application and

accom-

plished only with difficulty Patients prefer to continue in the same old ruts, and are indifferent in applying themselves to

any mental work. Consequently intellectual development not only ceases, but retrogrades, showing an increasing lack in judgment and a poverty of ideas, enhanced by a gradual failure of memory. Finally there is inability to acquire anything new, important facts are forgotten, and the past is recalled only as a somewhat confused and distorted picture. The defects of judgment and memory offer a fertile soil for the development of numerous more or less pronounced delusions.

CHRONIC ALCOHOLISM

167

These delusions tend to show a striking lack of judgment, are peculiarly ideas of injury, which sometimes take their origin

from isolated hallucinations, but more frequently from genuine perceptions which are falsely interpreted. In the more severe cases, a condition of advanced deterioration is
reached.

Moral

deterioration

symptom. There is and the patients soon lose sight and the sense of honor. This
their

a prominent and characteristic a profound change in moral character,
is

of the higher ideals of
is

life

especially noticeable in

own

estimation of their alcoholic habits.

They

dis-

regard their depravity with nonchalance, and claim that the liquor, taken for their physical benefit, does them no harm. When reprimanded for continued inebriety, they accuse a
friend of having given

them the

are driven to drink

by

liquor, or claim that they their wives. faithful promise to

A

abstain from further use of alcohol

may

be volunteered

but when encountered coming from a saloon an hour later, he fails to show any feeling of

by an

habitue*

;

shame.

Some claim that their work necessitates stimulation; others take only as much as can be regarded as a food. It is of interest to note the variety of conflicting excuses offered
by mechanics for the necessity of taking liquor: the cook, the fireman, and the iron moulder require it because of the great heat; while the night watchman, the truckman, and the iceman need it to keep off the cold. Many are driven
to drink
of a relative, a sick child,
incentives.

by unfortunate circumstances at home; the death and an ugly wife are frequent

patients lose all affection for their families, become indifferent to the tears of their children, have little interest in their welfare, disregard the real infidelity of their wives,

The

168
at the

FORMS OF MENTAL DISEASE
same time developing a
certain exaggerated feeling of

self-importance, noticeable especially in conversation. They are unable to take matters seriously, and display an un-

natural sense of humor,

drunkard's humor.

There is a corresponding increase of emotional irritability, which is more evident during intoxication. Patients are
quarrelsome, engage in strife and abuse on small provocation, misuse their children, and are destructive of clothing

and

furniture.

Their complete and abject submission

when

opposed by a superior force or when incarcerated is in marked contrast to their behavior at home. Their inoffensive behavior and attitude of humiliation before others

sympathy from the inexperienced. They become entirely unstable, cannot remain at home, visit from saloon to saloon, tramp from one city to another, and engage in their usual occupation only for a few days or
often excites

hours at a time, offering the excuse that they are physically unfit for continued labor. They leave the support of the
family to the wife and children,

they browbeat for enough money to keep them in liquor. Others degrade themselves by pawning clothing and furniture, and even steal
in order to satisfy their appetite.

whom

Physically.

The most prominent
first in

are: fine tremor, noticed

physical symptoms the more delicate move-

becoming general; muscular weakness with atrophy; uncertainty in gait; defective speech, sometimes thick, sometimes slurring, with occasional aphasic symptoms; peripheral neuritis; frequent headaches and sometimes verlater
tigo.

ments and

The tendon

reflexes are often increased, rarely lost.

there are frequently found areas of hypersesthesia, anaesthesia, parsesthesia, as well as painful pressure points. Epileptoid attacks occur in about ten to

In the sensory

field

thirty-five per cent, of the cases, usually during

an attack

of

CHRONIC ALCOHOLISM

169

delirium tremens or at the conclusion of a spree, but also during the course of chronic alcoholism and even after more

or less prolonged abstinence. They occur mostly in persons addicted to distilled liquors, and differ from genuine epileptic
attacks in that they are infrequent, but unusually severe, while the absences, ill-temper, and befogged states peculiar
to epilepsy are absent.

Furthermore, the epileptic attacks but not always, disappear with enforced abstinence. usually, In the sexual life there gradually develops, in spite of increased sexual irritability, impotency which often leads to jealousy and fornication. Furthermore, the progeny is

rendered not only susceptible to alcoholism, but is particularly apt to exhibit evidences of defective physical and men-

development, and also epilepsy. of the children of alcoholic mothers
tal

The
is

rate of mortality twice as great during

the

first

two years

of

life

as of non-alcoholic mothers.

This

rate also increases with successive childbearing, reaching as high as seventy-two per cent.

The chances of recovery depend upon the Prognosis. extent of mental deterioration and the character of the
treatment.
If the patients already

show moral

deteriora-

tion, prolonged treatment is apt to be of little avail; each time they relapse into their former habits, becoming at last

mental and physical wrecks. Cases when taken early and submitted to an extended treatment have a fair prospect
of complete recovery. In many reputable inebriate institutions from one-fourth to one-third of their cases recover

permanently.

The recognition of chronic alcoholism preDiagnosis. sents few difficulties in view of the history, the typical
and the physical symptoms, the latter being at times made more evident by the presence of neuritic symptoms. Treatment. The successful treatment of chronic alcofacies,

170

FORMS. OF MENTAL DISEASE

holism demands complete abstinence from alcohol in every form. A few patients are capable of carrying out this injunction successfully by themselves, but the vast majority, and especially those whose occupation brings them into bad associations, require the treatment afforded by a special
institution for alcoholics.

The

success of this or
is

any other
materially

plan of treatment in the

chronic alcoholic

impeded by the general

indifference of the environment

and

the attitude of physicians. Very many physicians, wholly ignorant of the favorable results of treatment in reputable
institutions, injudiciously advise the friends that it is of

no use to waste money hi a long sojourn at an

institution.

Even

institution physicians are not

beyond

criticism in this

respect,

and
is

will force the patient's discharge

"

as soon as

the patient himself does not appreciate the necessity of treatment or because of delusions resists any restriction of his liberty, then one must resort
the drink
If

out of him."

to a legal commitment to an institution, which is in many states even for a period of two years.

now possible

committed to your care the alcohol can be suddenly withdrawn, except in a few cases where

As soon
is

as the patient

is

there

a disturbance of the heart.

The abstinence symphallucinations,

toms, insomnia, anorexia, and

occasional

which

arise in consequence of withdrawal, tend to quickly

disappear, and should cause no alarm. Improvement begins If the patient in a few days, and progresses gradually. is received in a condition of drunkenness, ergot administered
in fifteen-minim doses

and repeated every two hours, or apomorphin given hypodermically, beginning with -^ grain and repeated until vomiting sets in and the patient falls to sleep, are remedies well recommended to ward off delirium tremens and to restore the equilibrium of the patient. But
for the benefit of the psychical effect,
it is

sometimes ad-

CHRONIC ALCOHOLISM

171

vantageous for the patients not to be relieved of all sufferSevere cases require a hospital residence of nine to ing.
twelve months, or even longer. An index of the power of resistance may be found in the patients' insight into their

own

condition,

and

willingness to prolong hospital treat-

ment.

In light cases it sometimes suffices to place the patient to live in a family and community where total abstinence pre-

Even here it is necessary that the patient be kept under close surveillance, especially during the first few months. A similar arrangement is sometimes an excellent plan to adopt for a time after discharge from an institution, particularly where the patient has to return to an unfavorvails.

able environment.
cessful in the

Hypnotic suggestion has been very suchands of some physicians, both in establishing

a disgust for liquor and in creating will power to combat the habit and withstand the enticements. Its employment,
if

successful, permits the patient to

remain at work and with

sive sanitarium residence.

the family, rendering unnecessary a prolonged and expenMuch depends upon the per-

sonality of the physician in charge of the patient or the individual at the head of the family, who must inculcate

the principles of temperance and rehabilitate the powers of A very important means for the assistance of resistance. the patient in his struggle against the alcoholic habit are the various temperance abstinence societies, the most powerful of

which in

this country are the

Society of the Catholic

Temperance Abstinence Church and the Good Templars.
:

Upon

series of characteristic

the basis of chronic alcoholism, there develops a psychoses namely, delirium tremens,

Korssakow's psychosis, acute alcoholic hallucinosis, alcoholic
hallucinatory dementia, alcoholic paranoia, alcoholic paresis,

and

alcoholic pseudopareses.

DELIEIUM TREMENS

DELIRIUM TREMENS is characterized by the rather sudden development of numerous fantastic hallucinations, mostly of sight and hearing, indefinite and changing delusions, principally of fear and often of a religious nature, with clouding of consciousness, restlessness, tremor, ataxic disturbances, with rapid

course

and good prognosis.

Etiology.

The

etiology of delirium tremens

means thoroughly understood.

by no In the greater number of
is

cases excessive alcoholism appears to be the important factor, though it is generally recognized that the disease may de-

velop in connection with an acute febrile disease or some pronounced emotional excitement, as imprisonment and
injury.

Careful analyses of cases tend to

show that bodily

injury is really significant in not more than five to ten per cent, of cases, while the disease, pneumonia, occurs far more

frequently (Bonhoeffer forty per cent.). It seems probable, therefore, that in chronic alcoholics, any disturbance which

overtaxes the functional activity of the body or disturbs its equilibrium tends to produce delirium tremens; thus, severe
chronic disturbances of the general nutrition are of great importance among the predisposing factors, such as that arising

which occurs in most cases, and prevents the many weeks and even months. Furthermore, the symptoms of delirium tremens in no way resemble those of acute alcoholic intoxication, hence the

from

gastritis,

taking of sufficient food for

delirium cannot be due to alcoholic intoxication alone.

Again, the amount of alcohol ingested immediately before the attack seems to bear no definite relation to it, as, in

some

cases, the patients

have had no alcohol for weeks;

withdrawal, and In the in some it appears in spite of continued drinking. of delirium tremens, other particular factors development
others develop the condition only

upon

its

172

DELIRIUM TREMENS

173

must be at work besides the excessive use of alcohol. Just what they are is not definitely known. It is believed that the numerous and severe organic changes accompanying chronic alcoholism play an important role and undoubtedly produce, as shown by the poverty of the blood and abundance of adipose tissue, profound disturbances of metabolism. Jacobson points to the presence of a decomposition material
in the intestine; Hertz places delirium tremens

on the same

basis as uraemia;

Elsholz finds blood changes indicative

of a particular auto-intoxication; and Bonhoeffer suggests an intoxication arising out of the process of digestion, the product of which is normally secreted by the lungs, which

intoxication

become
tremens.

particularly apt to develop when the lungs diseased, as so frequently happens in delirium
is

findings in the blood and urine, which result directly from the action of the alcohol or indirectly through the fever, also the frequent occurrence of fever and

But the

mental picture, point conclusively to the fact that in delirium tremens we have to do not only
finally the characteristic

with the simple increase of the chronic alcoholic intoxication, but with an essentially different sort of an intoxication to which
the excessive alcoholism is only

common

a predisposing factor. The occurrence of abortive attacks of delirium tremens,

preceding for some time the genuine attack of delirium tremens, seems to distinctly favor this view, and to point to the additional fact that in delirium tremens there is only a

sudden increase of disturbances which have been present some time, but in a milder degree.
Male patients greatly predominate in delirium tremens. According to Bonhoeffer seventy-four per cent, of cases occur between thirty to fifty years of age. The disease occurs more
frequently in

summer than

in winter.

Pathological Anatomy.

Besides a pronounced degree of

174

FORMS OF MENTAL DISEASE
stasis

venous

and edema
*

of the brain,

which

is

usually pres-

ent, Bonhoeffer

finds a

marked degree

of fibre atrophy in

the radial fibres of the central convolution, in the fibretracts of the worm of the cerebellum, and especially in the

columns of Goll in the cord, while there is little or no alteration in the parietal or Broca convolutions; these lesions are not found in simple alcoholism. In the large pyramidal
cells

and

in the

motor

cells of

the anterior central convolu-

tions, the outline of the unstainable

completely lost, a considerable distance.
observed.

substance is more or less and the processes are markedly stained for
of cells

A

number

Occasionally nuclear changes are appear to be destroyed. A

similar condition prevails
calls attention to

among

the Pur kinji

cells.

Nissl

and

to a cell

a partial destruction of the cortical cells, change, which is suggestive of other acute cell

changes, in which there is staining of the achromatic substance, especially the axis cylinder processes, vacuolization in

the

cell

substance and moderate swelling, besides chronic

cell changes and an increase of glia. part of these changes are due to chronic alcoholism, among which should be added miliary hemorrhages, which in places occur in great numbers,

A

particularly about the nuclei of the eye muscles, as well as In the internal organs there are certain vascular changes.

found fatty degeneration and fibroid myocarditis of the heart,
cirrhosis of the liver,

and acute and chronic

alterations in

the kidneys.
five of

Furthermore, Jacobson discovered in forty-

seventy-two autopsies an acute hyperplasia of the in nine cases a hypersemia. spleen, Among the first symptoms to appear Symptomatology. are the sense deceptions; illusions and hallucinations of all

and

the senses, but more especially of sight and hearing.
Bonhoeffer, Monatsschr. f. Psychiatric u. Neurologic, Archiv f. Psychiatrie, XXXI, 3.
I,

These

229; Troem-

ner,

DELIRIUM TREMENS
appear at
first

175

during the day and annoy the patients conThey are perceived with great clearness, and with stantly. the terrifying content produce a marked alteration in the
emotions.

The

patients see

all sorts

of animals, large

and

small, moving about them; rats scamper about the

floor,

serpents crawl over the bedding, insects cover their food, and birds of prey hover about in the air. These forms almost

always show more or

less active

movement, depending upon

the restlessness of the body and the eye movements. Double sight is sometimes observed. This unsteadiness may in a

measure account for the frequency with which the flitting and scurrying animals appear. Fantastic forms are seen, mermaids, satyrs, and huge quadrupeds. Crowds press

upon them, troops
under the bed.

file

by.

omnipresent, peering in at the

The devil and his imps are windows or crawling from
the roaring of beasts,

The patients hear all sorts of noises,

ringing of bells, firing of cannons, crying of distressed children. They are taunted by passing crowds, are threatened with death, are cursed, called traitors, thieves, and murderers.

Parsesthesias of

the skin lead to the ideas that

ants are crawling over them, that bullets have entered the body, and even the absence of wounds does not deter them

from exposing limbs which have been shot

full of missiles.

irons are being applied to their backs, and dust is thrown in their faces. They can detect the odor of gas, sulphur fumes are being forced through the keyhole. Real

Hot

room assume life; the tufts on the bedding become creeping things, and the bedposts, demon guards. The content of the hallucinations is not always of a terrifying nature. Sometimes angels are seen; beautiful music is
objects about the

heard.
Christs,

God appears
and

to them, announcing that they are empowered to cast out devils; they are com-

176

FORMS OF MENTAL DISEASE

manded

to go to confession and to proclaim the gospel message; they are in beautiful surroundings, are richly dressed, in palatial quarters, attended by lovely maidens.

Sometimes the scenes are of a lascivious character. Occasionally there is a mixture of the fearful and the beautiful, but more often, when there is a change of the emotions, the
former
is gradually replaced by the latter, as the course of the disease progresses. The hallucinations in a few cases, and especially after the height of the disease has been passed,

are nothing more than a passing show for the patients; they then gaze at the hideous forms and listen to the various
noises quite unconcerned. The results of various experiments

seem to indicate that

the hallucinations and illusions originate in disturbances of the central processes. Hallucinations seen through a
colored glass are not similarly colored. Also the hallucinations can be made to appear by directing the patient's

attention to their sensory

fields,

and by asking them what
enter into the picture of

they see and hear.

The various

hallucinations

may

an occupation delirium, when the patient is busy gathering up the gold lying about him, driving a flock of sheep, leading an orchestra, or addressing an audience. On the basis
of these delirious experiences, the patients

may

develop a

whole fabric of delusions concerning their environment and their experiences, but these delusions are never elaborated, do not influence the thought or action to any extent, and are
quickly forgotten. There never develop delusional ideas in reference to the personality of the individual. The patients

always

know who and what they are. The process of perception in itself, according to Bonhoeffer, 1
1

does not present any very striking disturbances, the pain,
Bonhoeffer, Der Geisteszustand der Alcoholdeliranten, 1897.

DELIRIUM TREMENS

177

muscular and temperature sense of the skin, as well as the
acuity of sight and hearing and the measuring of distances by the eye, being normal. The field of vision is sometimes
restricted, the recognition of color is uncertain,
tactile sensibility

and the
is in-

on the

finger tips
is

and the forehead

sometimes very greatly disturbed, many patients being unable to sit up, to stand or walk, and very anxious to remain in bed. This, he becreased.

The

sense of equilibrium

lieves,

accounts for the disorientation of the body in space.

Patients frequently complain that the floor is shrinking and that the walls are coming together, which may be due to disturbances of the eye muscles or of the labyrinthine
sense.

Disturbances of apprehension are prominent. There is defective interpretation of the impressions excited in the
various sensory
to obtain

with the result that the patients misinterpret noises, do not recognize pictures, and are unable
fields,

any sharp and clear impressions. The disturbance becomes more apparent when the patients attempt to read.
Instead of correct sentences, they read a senseless series of

words and sound associations, noticeable especially when the type is small and indistinct. Sometimes there is no relation at all between the reading and the subject-matter. This same defect is sometimes due to aphasic disturbances. shows marked disturbance. While it is for instance, possible to hold the attention for a moment, to get a response to your reading test, at the long enough
attention also

The

next the attention

your efforts. The promakes the disturbance of apprehension appear even greater than what it is. Forcible
fails in spite of

nounced disturbance

of attention

hold the patients for a short time, but they usually relapse, and they note only those objects that especially attract them.

language

may

178

FORMS OF MENTAL DISEASE
is

always a moderate clouding of consciousness. The surroundings are not correctly comprehended, and the ideas

There

which are excited by occurrences in their immediate surroundings are confused and contradictory.
degrees of insensibility are
there
is

The

greater

found only in severe cases and

especially following epileptoid attacks.

On

the other hand,

profound disturbance of orientation, except in the The surroundings are mistaken for the barlightest cases. the church, or the prison, and strangers are greeted room,
as old friends.

Time

orientation
illness-

is

also incorrect.

Usually

the duration of the

seems to the patients much
is

prolonged, even to months.

The memory

for

remote events

well retained.

The

patients recall correctly where they live and facts concerning their families and occupation, and the length of time they may have resided in different places. But the impressibility of the

memory

is

greatly impaired, as

may be

determined by giving the patients a series of words or numbers to recall later. Memory for recent events is very defective, especially as regards the temporal arrangement.
Fabrications of

memory

frequently appear.

The train of thought is mostly coherent, yet the patients show considerable distractibility. The goal ideas are flighty and not very well fixed. During a conversation trifling incidents or hallucinations
off into

may

hinder the thought or lead
patients experience

it

various directions.

The

diffi-

culty in collecting their thoughts, are unable to recognize
contradictions,

and

fail

in trying to solve problems

which

require thought. In emotional attitude the patients are anxious and fearful or happy and cheerful, depending upon the character of the
hallucinations or illusions. intense fear to jolly

They may change rapidly from laughter, and even indulge in witty re-

DELIRIUM TREMENS
marks.

179

and the fear of death may rapidly and in this way there may develop a mixture of concealed anxiety and humor, when it seems as though the patients, in spite of the dreadful pictures and fears, still recognize more or less clearly the humorous impossibilities and contradictions in their delirious experi-

Thus

elation

follow each other,

ences.

In actions the patients are more or less restless and talkative. They are seldom able to engage in work, though
occasionally a patient continues at his occupation until the disease is well established. Usually they take an active part

numerous hallucinations. They plug the ears to out disagreeable noises, crawl under the bed to elude keep persecutors, escape from the window to get away from the
in their

sulphur vapors and the enemies waiting outside the door; they answer the imaginary voices, run to the station for
protection, or

amuse themselves with

their beautiful sur-

roundings and join in the happy company of imaginary

Sometimes they are assertive and aggressive, demanding attention or carrying out divine commands. When in fear they sometimes commit assaults, but they rarely
revellers.

attempt

suicide.

Many chronic alcoholics develop what in their own parlance " is called a touch of the horrors," which in reality is an abor1 tive form of delirium tremens. Some of these cases come under
the care of the family physician, but the majority of them go without medical attendance. The symptoms are those of the prodromal stage of delirium tremens. During a debauch or following abstinence or mental shock, there develops some parsesthesia, a vague feeling of fear, as if some one were
constantly behind the patients, the slightest noise causing them to be startled. While in this state they have isolated
1

Berkley, Mental Diseases.

180

FORMS OF MENTAL DISEASE

One patient saw for a hallucinations of sight and hearing. moment a number of rats scampering across the floor, others
were attracted by unnatural voices.
It very

frequently

happens at night that some object appears at the window The patients are perfectly confor a second and is gone.
scious,

and appreciate

their condition.

Some

of the physical

signs of delirium

tion

is

tremens are usually present. The condiof short duration, rarely lasting over a few hours or
Besides the various sensory disturbances,

days.
Physically.

such as neuritic disturbances, parsesthesias, hypersesthesias, and circumscribed areas of anaesthesias which may form the
basis for illusions

lack of

and hallucinations, there is sometimes a insensibility which will permit the patients to sustain
There
is

severe injuries without complaint.

often present

great muscular weakness. The muscular movements tend to be coarse and unsteady, and the gait uncertain and staggerThere is some ataxia and pronounced tremor of the ing. tongue and fingers, and sometimes of the extremities and Speech is often ataxic and paraphasic, with maleyelids. position of words and syllables, and in the severest cases may be slurring and unintelligible. Occasionally in the
severe cases muscular spasms are noticed. Epileptiform seizures are frequent, occurring mostly before the attack,
in ten per cent, of the cases one to

break, less often during the attack,

two days before the outand sometimes accom-

panied by transitory paralytic symptoms, such as hemiThe tendon reflexes are exaggerated. Insomnia is paresis.

marked from the first, and persists unless the patients become stuporous. The condition of nutrition suffers, because of the small amount of nourishment ingested, which is due in part to the delusions of poisoning and in part to the
gastritis.

There

is

apt to be a slight

rise of

temperature

DELIRIUM TREMENS
during the
grees.
first

181

The pulse

few days, rarely reaching one hundred derate is low as well as the respiration,
is

and

occasionally there

profuse perspiration.

In a large percentage of cases the urine contains albumen and casts, which clears up with the psychosis. Elsholz finds
in the blood a relative leucocytosis, with a diminution of the

eosinophiles at the height of the psychosis. The duration of the delirium varies from a few Course.

days to two weeks, rarely extending beyond three weeks. The improvement comes with sleep. The hallucinations
usually fade away slowly, though sometimes they disappear within a night. With the improvement of sleep the physical

symptoms disappear

gradually. The memory of the events of the psychosis, in spite of great clouding of consciousness, is sometimes surprisingly clear, though it later tends to
fade.

A few suffer a second attack few days or even a week of clear consciousness have intervened, and in spite of the fact that they have
after a

show rapid the improvement of sleep.
Not
all

cases

clearing

up

of

symptoms with

Others show a complete alteration in the character of the psychosis after the hallucinations and
continued abstinent.
illusions
istic

have disappeared, some developing the character-

dementia.

polyneuritis psychosis or the alcoholic hallucinatory certain number of cases pass into alcoholic

A

paranoia, to be described later. In the more severe cases the physical signs become more prominent and there develop convulsions, muscular twitch-

and disturbances of the eye muscles. At the same time the insensibility and the incoherence increases, the movements become weaker and the pulse smaller, and finally death ensues, with sudden loss of consciousness or
ing, ataxia,

collapse.

182
Diagnosis.
if

FORMS OF MENTAL DISEASE
The
diagnosis of the disease
is is

not

difficult

known. Fever delirium and the epileptic befogged states may be confused with delirium tremens. In the former there is a more marked
previous history of alcoholism
clouding of consciousness, and, especially in the epileptic condition, confused delusions of a religious character stand

moderate restlessness without impulsivethe active hallucinations, and the muscular tremor of ness, the alcoholic.
in contrast to the

The delirium

of dementia paralytica is differentiated

from

the alcoholic delirium by the previous history of change of character, evidences of failure of memory and judgment,
paretic physical signs,

and the more profound clouding of with a change of personality. consciousness, The outcome is usually favorable. In the Prognosis.

unfavorable cases (three to nineteen per cent.) pneumonia is the chief cause of death and greatly increases the fatality.

Other causes of death are cardiac
ing injury,

failure, infection follow-

and

suicide.

the development of delirium tremens in chronic alcoholics who have suffered injury or

Treatment.

In warding

off

have developed pneumonia, one should withdraw the alcohol at once and attend particularly to nutrition and sleeplessness.

Frequently repeated doses of ergot or the administra-

tion of
respect.

apomorphin hypodermically

(see p. 170) aids in this
is

The

first

indication for treatment

the establish-

ment

of proper nutrition, which requires frequently repeated administration of small quantities of liquid. If necessary, Gastritis with nausea artificial feeding should be resorted to.

and vomiting may necessitate lavage. The second indication is to combat insomnia, for which purpose a combination of 3J grains each of chloral, potassium, and sodium bromide is most efficient, repeated every hour until sleep is secured.

DELIRIUM TREMENS
In case the cardiac condition
will

183

not permit the use of chloral, paraldehyde or chloralmide may be substituted. The patient should be confined in bed and watched constantly.
If

excitement increases to such an extent that the

patient cannot be kept in bed, then the prolonged warm bath must be employed (see p. 140). Great excitement may
necessitate its continuous use, combined sometimes with the use of chloral and the bromides or paraldehyde, or in its

extreme

cases, the use of hyoscine.

As already indicated, alcohol should always be withdrawn.
In case the slightest evidence of cardiac weakness develops, one should not hesitate to make use of caffein, camphor, or camphorated oil, or in urgent states normal saline
infusion.

KORSSAKOW'S PSYCHOSIS
described a number of cases of apand associated with polyneuritic symptoms, which were characterized particularly by a profound disturbance of the impressibility of memory, disorientation, and a tendency to fabrications of memory. Later experience

In 1887 Korssakow

l

parent toxic origin

demonstrated that while this psychosis occasionally appeared in connection with other toxic states (see p. 134), it developed

most often on the

basis of chronic alcoholism.

It also be-

came apparent that the polyneuritic symptoms are not a constant accompaniment of the psychosis. The intimate relationship of this psychosis to Etiology.
Korssakow, Archiv f. Psychiatric, XXI, 669; Allgem. Zeitsch. f. XLVI, 475; Tiling, ebenda, XLVIII, 549; Uber alkoholische Paralyse und infektioese Neuritis multiplex, 1897 Jolly, Charite'annalen,
Psychiatric,
;

XXII; Moenkemoeller, Allgem.
Raimaim, Wiener
15 ;
klin.

Psychiatric, LIV, 806; Wochenschrift, 1900, 2 Elsholz, ebenda, 1900, Heilbronner, Monatsschrift f Psychiatric, III, 459.
f.
;
.

Zeitschrift

184

FORMS OF MENTAL DISEASE

alcoholism has already been pointed out. Jolly regards it as a severe form of delirium tremens, while Bonhoeffer deIt develops in scribes it as a chronic alcoholic delirium.
It is three per cent, of the cases of delirium tremens. much more apt (eleven per cent.) to occur during the second

or

subsequent

attacks

of

delirium

tremens.

Women

appear to suffer in a proportionately larger percentage than

men.
There is an extensive destructive Pathological Anatomy. process involving the nervous tissue from the cortex to the
peripheral nerves. The nerve cells present the usual signs of an acute process while the nerve fibres give evidence of varying degrees of destruction, especially in the region of the
central convolutions, when there is a prolonged course of the disease. In the spinal cord there is an extensive atrophy
of the fibres, particularly in the
ticular

columns of Goll. Of parare the numerous small hemorrhages, ocimportance curring especially in the central gray matter, where they are

regarded as the cause of the oculomotor paralyses. The acute hemorrhagic polyencephalitis superior, described by

Wernicke, according to Elsholz and Bonhoeffer, is frequently associated with Korssakow's psychosis. The above anatomical lesions, which are indicative of an extensive destruction of nerve tissue, in reality are only what one would expect to find in severe alcoholic intoxication.

Symptomatology.
to those of

The symptoms at the onset are similar delirium tremens. But after the usual course of
and insomnia disappear. The and in addition there

the delirium symptoms, disorientation continues, while the
hallucinations, restlessness,
delirious experiences are not corrected,

develops a very striking disturbance of impressibility of memory (Merkfahigkeit). The symptoms sometimes follow

a rapidly developing stupor with hallucinations, and they

KORSSAKOW'S PSYCHOSIS
still

185

more

rarely develop gradually

from the chronic alcois

holic state.

In severe cases this disturbance of memory

so pro-

nounced that the patients cannot remember for a few minutes or even seconds that which they have just experienced. They are conscious and understand what is said to them,
yet they are wholly unable to put together their recent experiences or to form any picture of the course of events in

They do not know what has happened in the past hour, although in the meantime they have washed and prepared for and eaten dinner and been visited by the
their lives.

physician, and, indeed, even if told all this, they cannot fit it into their memory and correct the defect. few very

A

striking impressions

may

be retained, but they are never

connected with the events immediately preceding or followThe first result of this disturbance of memory is a ing.
complete loss of orientation. The patients have no conception of the time. They cannot tell where they are or those

about them, and usually greet the physician as an old acquaintance, though they cannot recall the name.

While the memory

is

more

particularly affected for events

since the onset of the psychosis, yet it sometimes happens that there is a distinct loss of memory for events extending

back several months or even years. They cannot tell you how they have been employed, or where they have been, or have lived during all this time. Some forget that they are
married or have children.
called,

A few striking incidents may be re-

but the time of their occurrence cannot be established.

The

are not only not recognized by the patient, but are very apt to be filled in with falsifications of memory, which are related by the patient with a feeling of
lapses in

memory

absolute certainty. These falsifications may apply only to the lapses of recent date. The patients then relate visits

186

FORMS OF MENTAL DISEASE

which they have just had, or journeys which they have made, and give a detailed account of the good times they have had, while in reality for months they have been leading a wholly uninteresting and monotonous existence. These fabrications can usually be drawn out by questioning and influenced by suggestions. The fabrications are not always limited to mere filling the lapses of memory with ordinary experiences,
but the patient
gether

may strive to amplify the incidents with altofictitious events.

new and

This latter tendency is

pronounced only during the earlier stages of the disease. Indeed, the fabrication may extend to an intricate and fantastic falsification of the last ten years of the patients'
lives,

concerning which they relate

all

kinds of wonderful

experiences.

The apparent accuracy

of these fabrications

forcibly impresses one, together with the wealth of detail

and

the absolute certainty which they possess for the patient at the time. Although the facts are frequently altered, each

time they are related as clearly and assuredly as if they had occurred only yesterday. Occasionally, expansive and depressive delusions are added, but these also tend to change rapidly and as suddenly appear and disappear. Some-

times hallucinations also occur at the beginning, which later
disappear. The function of the intellect outside of the disorders

already
patients

mentioned

is

not

particularly

impaired.

The

show good judgment on other matters, understand
answer questions to the point,
cleverly conceal the lapses in their

facts presented to them,

and know how to

memory.

the other hand, they do not possess a clear insight into their condition and are unable to employ themselves profitably.

On

They can write letters well and carry out orders, but they become shiftless and lead a thoughtless and inlife.

active

KORSSAKOW'S PSYCHOSIS
The emotional

187

attitude at the onset is mostly anxious, but becomes one of indifference and apathy, though sometimes there is distrust and irritability, while in other

later it

cases a certain degree of good Usually the emotional attitude

humor
is

or elation exists.

also easily

changed by

suggestion into one state or another. The conduct and actions of the patients after the subsidence
of the delirium

become

orderly.

The

patients

may com-

plain a little about their surroundings, but they are mostly As a result of faulty memory they are always quiet. neglecting to attend to personal duties, or repeating what

they have already done; hence the same questions are frequently asked, and numerous letters are rewritten. Delusions,
if

The

present, do not greatly influence the conduct. physical symptoms are usually those of alcoholic

These, however, may be absent. The extent of the symptoms also may vary considerably, but usually they are confined to minor paralytic signs, atony and reduced
neuritis.

volume

of

Romberg
pressure;

certain muscle groups, especially in the legs; signs; sensitiveness of the nerves and muscles to
less extensive anaesthesia, parsesthesia, or

more or

hypersesthesia; loss, seldom increase, of the tendon reflexes; cystic disorders, some degree of ataxia; difficulties of

deglutition

and speech; and

paresis of the

facial

nerve

and

especially paralysis of the eye muscles (abducens).

The

pupils are often unequal, and notched, and sometimes do not react to light. There is also tremor of the fingers, and fre-

quently a history of epileptiform attacks. Furthermore, symptoms indicative of chronic alcoholism may be present,
as nephritis, hypertrophy, or atrophy of the
ascites,
liver, icterus,

and edema;

also faulty nutrition, anorexia,

and some-

times nausea.
Course.

Following the rapid development of the disease,

188

FORMS OF MENTAL DISEASE
is

usually a long one. In some cases death ensues from paralysis of the heart or respiration. Not infre-

the course

quently a rapidly developing tuberculosis leads to death. After a period of several months, there may be gradual improvement, with disappearance of the neuritic symptoms,

a return of orientation and improvement of memory.
small

In a

number

of cases the

improvement may,

in the course

of five to nine months, be sufficient to permit the patient's

returning home, yet there regularly remains a considerable increased susceptibility to fatigue, uncertainty of memory, emotional apathy or irritability, weakness of will, and limited

Further indulgence in alcohol tends to quickly inUsually the disease tertensify these residual symptoms. minates in a permanent dementia, which is particularly
activity.

characterized by the persistence of falsifications of memory. The conditions of excitement at the onset of Diagnosis.

the post infection psychoses may be differentiated by the fact that clouding of consciousness is much more pronounced, and hallucinations and illusions are more in the background;
further, the alcoholic

absent, the emotional attitude does not present the alcoholic characteristics, and finally the Paresis is distinprognosis is distinctly more favorable.

tremor

is

guished by the usual history of a gradual onset. Pronounced neuritic symptoms with paralysis of the eye muscles and the alcoholic tremors speak for Korssakow's psychosis, while
indications
of

graphia, and stupid or humorous emotional attitude of the alcoholic con-

aphasia, hesitating speech, marked paracerebral paralysis point to paresis. Again, the

trasts with the silly happiness of the paretic, while the only intellectual disturbance of Korssakow's psychosis is seen in

the memory, which may not involve the more remote events of life, as in paresis. Presbyophrenia also is characterized

by impaired

impressibility of

memory,

loss of orientation

ACUTE ALCOHOLIC HALLUCINOSIS
and fabrication but
;

189

this disease occurs

mostly in the senile

may not be preceded by an alcoholic history, and is not accompanied by neuritic disturbances. Again, the activity of the patients is greater; they are communicative,
period,

often garrulous, trouble themselves about the environment, display a childish emotional state and a certain busyness, The diagnosis may be difficult if the especially at night.

presbyophrenic
alcoholism.

patient has

been addicted to excessive

During the early stages of the disease the treatment is identical with that in delirium tremens The alcohol must be absolutely withdrawn, (see p. 182).
Treatment.

and the patient placed

either in

an

institution or in a

particularly satisfactory family environment, because of the great weakness of will displayed by the patients. Later in

the course of the disease,
electricity,

it

may

be necessary to employ

massage, and gymnastic movements in order to combat the muscular atrophy accompanying the neuritis. Some improvement of the memory disturbance may result from systematic mental exercises.

ACUTE ALCOHOLIC HALLUCINOSIS
This psychosis is characterized by the sudden development of coherent delusions of persecution, based mostly upon
hallucinations of hearing, with barely sciousness.
Etiology.
l

any clouding

of con-

The

etiology of acute alcoholic hallucinosis

is

one identical to that in delirium tremens (see p. 172). case should develop into delirium tremens and another into
acute alcoholic hallucinosis
yet unknown. The various explanations offered for this by Bonhoeffer and others are
is
1

Why

Mitchell,
p. 251.

Types

of Alcoholic Insanity.

Amer. Jour,

of Ins. Oct. 1904,

190

FORMS OF MENTAL DISEASE
Acute alcoholic hallucinosis represents, in

not satisfactory.

America, forty-five per cent, of the cases of alcoholic insanity committed to institutions, and occurs mostly in men of middle
life,

many

of

whom

have been habitual daily drinkers for

years.

Symptomatology. Occasionally, there are a few prodromal systems, such as indisposition, headache, dizziness,
insomnia, and irritability. The onset is usually sudden. The patients at first are disturbed during the evening or at
night by indefinite noises, like shouting voices, cryings, and
ringing
definite
bells.

These

hallucinations

soon

become more

when they hear their own names called and numerous epithets. The patients then hear remarks about themselves, which appear to come from the next room or from
fellow-workmen.

These remarks are usually quite

clear,

and occasionally are heard in only one ear. The voices are recognized as those of an acquaintance, a chum, or a fellowworkman, but rarely as those of the immediate family, and consist of imprecations and references to misdeeds of their
past

They hear themselves called murderers, liars, and thieves. They learn that they are to be electrocuted,
lives.

that the wife

is

unfaithful, or that the children have been

drowned. They are laughed At times they overhear long
welfare, in

at because of their anxiety. discussions concerning their
of their past lives are reis

which various events

hearsed or an indictment for murder
Again, a group of

read against them.

men under their window discuss means of them and bringing them to a public place for the capturing purpose of having them lynched. All this is so very real to the patients that it is impossible to convince them to the

contrary. Furthermore, it almost always happens that the voices are not spoken directly at them, but they only overhear what is being said among others about them. The

ACUTE ALCOHOLIC HALLUCINOSIS
content of these hallucinations
nature.

191

is always of a depreciatory Besides these numerous hallucinations of hearing,

there are a few hallucinations of sight, especially at night. Strange and threatening forms appear before them, some

crawling from under the bed, others creeping on the wall; brilliant specks come across the field of vision, and they may even see double. At times the food has a peculiar taste,

and

excites suspicion.

In connection with these various hallucinations there
regularly develop pronounced delusions, mostly of a depresThe patients believe that they are the center sive nature.
of attraction; every one about

them watches and threatens

them.

Their every thought and action is known and commented upon. Passers on the street jeer at them, fellow-

passengers on the trolley watch them closely, visitors in the factory are told all about them and stand and gaze at them,

enemies shoot through the fence at them, and detectives in citizen's clothes follow them wherever they go. They are

on the alert for impending arrest, or they go into hiding, and refuse to leave their homes. These patients argue that they are condemned to die, and show considerable emotion. Fellowdistrustful of their surroundings, are constantly

patients refuse to speak to them because they are implicated in the seduction of their wives. Sometimes they refuse to

answer questions or associate with any one until brought to
the court

room

for the

supposed

trial.

At times they

find

consolation in prayer and in reading the Bible. These various delusions usually remain within the realm of possibility, and appear more like attempts on the part of the
patient to explain the hallucinations. Occasionally, however, the delusions are of a fantastic nature and simulate

those occurring in delirium tremens, sometimes also being associated with expansive delusions.

192

FORMS OF MENTAL DISEASE

consciousness is barely disturbed, there being only a dazedness. Yet at night, and at the onset, there slight may be a slight transitory delirium. The patients are mostly
oriented, their speech coherent,

The

and they are able

to

make

an accurate statement

of their

symptoms, except occasionally

They rarely possess clear insight, but they often realize that they are different, and frequently accuse their persecutors of drugging

in giving the correct time of their occurrence.

them
"

or

making them

crazy.

Others claim that they are
onset
is

only

nervous."
attitude at the

The emotional

usually that of

anxiety, but later in the course of the disease there is that characteristic mixture of anxiety and cheerfulness seen in

delirium tremens,

when

the patients relate their frightful

experiences with indifference, or perhaps laugh at the absurdity of their attracting so much attention. When not
in fear, they are quiet, reserved,

and

in replying to questions

are monosyllabic. In conduct the patients

may remain
work

quite orderly,

and not

infrequently continue at

for days

But even during
silent,

this period peculiarities of

as the result of their delusions.

and even weeks. manner develop They become reserved,

and avoid acquaintances;

later they often apply to the

police for protection or hide under the bed, and some even attempt suicide. In our experience these patients are some-

into their

times the most dangerous of the insane. They take the law own hands, purchase firearms, and assault those

maligning their character or planning their destruction.

The sleep is regularly disturbed. The appetite fails and there is a loss of weight. The reflexes are occasionally exaggerated, and tremor of the tongue and hands
Physically.
is

often present, though not always.

Occasionally, there are

neuritic

symptoms.

ACUTE ALCOHOLIC HALLUCINOSIS
Course.
or subacute.

193

The course

of the psychosis

may

be either acute

When acute, the duration varies from two to three weeks, with rapid disappearance of the symptoms, sometimes during a night. The prospect for a short course
seems better the nearer the symptoms approach those of
Occasionally, abortive forms of acute alcoholic hallucinosis are observed, in which the patients for

delirium tremens.

a few hours or a couple of days suddenly develop isolated transitory hallucinations, with anxiety, and a few persecutory
delusions, such as, that they are to be poisoned, assaulted

by fellow-workmen, or are watched by the police. In the subacute form the symptoms may persist from one to eight months, with numerous fluctuations, and then disappear
gradually.

The memory
The

for

events of the psychosis

is

usually excellent.
Diagnosis.
differentiation
is

and acute
fined.
is

alcoholic hallucinosis

between delirium tremens by no means sharply de-

There are cases of the latter in which the orientation
for only a short time, hallucinations

markedly disturbed

of hearing are very pronounced,

and there seems

to be a

definite delusional connection between the various individual morbid experiences, while, on the other hand, the difficulty

of apprehension, the disturbance of the impressibility of

memory, the presence
delirium tremens.

of visual

suggestibility, restlessness,

and tactile hallucinations, and tremor give the stamp of

Provided they are not simply cases of

undeveloped delirium tremens, may they not possibly represent a combination of delirium tremens and acute alcoholic
hallucinosis, similar to those cases of delirium

tremens occa-

sionally seen in epileptics, paretics, hebephrenics, and

manics ?

But usually the retention of a good of restlessness and striking physical
of hallucinations of hearing

orientation, the absence signs, the predominance

with coherent delusions based

194

FORMS OF MENTAL DISEASE
sufficiently

upon them, and a more prolonged course are

distinctive evidences of acute alcoholic hallucinosis.

The

differentiation

from dementia

prcecox,

particularly

the paranoid form, may be difficult, but in dementia prsecox the onset is far more gradual: there is stupidity; looseness
of thought; a lack of energy for work; peculiar conduct, such as, staring, impulsive acts, and catatonic signs. The in dementia prsecox are directed to the while in the alcoholic psychosis the patient simply patient, overhears what is said. The delusions involve mostly the

hallucinations

physical

and mental

personality,

which in the alcoholic

psychosis are not involved. Finally, the emotional attitude is superficial, while in the acute alcoholic hallucinosis the
is genuine and often desperate, except for the occasional appearance of the alcoholic humor. Paresis may be

anxiety

differentiated

of paretic physical signs

by the same signs in addition to the presence and weakness of memory and judg-

ment.

Some

cases of manic-depressive insanity

may

present

some

similarities to acute alcoholic hallucinosis,

but they

can be successfully differentiated by the previous history
to delusions of self-accusations, which are absent in the alcoholic condition.
of the case,

and by tendency

usually favorable, as a large proportion of the acute cases recover. There is great danger of relapse with continued drinking, and subsequent attacks
Prognosis.
is

The outcome

are

more prolonged. Some patients have four or five attacks. The outlook in the subacute cases is not as favorable, as less than twenty-five per cent, wholly recover. In some cases

there finally develops a condition of permanent dementia, with hallucinations and delusions.

Treatment.

The

chief indications are the absolute withdiet,

drawal of alcohol, the administration of a nutritious

and incessant watching to prevent injury

to self

and

others.

ALCOHOLIC HALLUCINATORY DEMENTIA

195

The course

of the disease

may sometimes

be cut short at the

onset by the use of hypnotics to overcome the insomnia and of the prolonged warm bath to ameliorate the anxiety.

ALCOHOLIC HALLUCINATORY DEMENTIA
This type of alcoholic psychosis, provisionally called alco1 hallucinatory dementia (or alcoholic paranoia ), is

holic

characterized
lucinations,

by the sudden development

of

numerous

hal-

fluence

and

many depreciatory delusions of reference, persecution, associated somatic delusions,

in-

and

occasional change of personality, with some emotional anxiety and irritability, usually leading after a long course to moderate

dementia.

It frequently represents the

end stage

of the

acute alcoholic hallucinosis and as often follows delirium
tremens.

Symptomatology.

The onset

is

sudden.

If

acute

al-

preceded, the patients having become oriented and quiet, and having corrected at least a part of their delirious experiences, continue somewhat constrained and suspicious. Then hallucinations, particularly of hearing, develop again,

coholic hallucinosis or delirium

tremens have

and the

patients complain are reading their thoughts, and that they are being influenced in various ways. They feel that they are being hypnotized,
electrified, or

of hearing threatening voices, that others

chloroformed, are experimented upon when think that men are breathing on them, smearing asleep; mucus over them, changing their clothing, and creating disgusting odors about them.

Comments

daily papers about themselves, and to them from the stage. Very often their delusions have a

are printed in the actors make allusions

sexual content,

when they claim that they have been ashave their semen drawn off nightly, and that their saulted,
1

Luther, Allgem. Zeitschi fur Psychiatric, LIX, 20, 1902.

196

FORMS OF MENTAL DISEASE

organs are being shrunken up. These delusions are usually not elaborated, but remain unchanged from week to week, and are almost always expressed in the same phraseology.

Witches and

spirits are

everywhere, assuming various forms,

offering threats; everything is poisoned, and cannot escape the hypnotic influence. Occasionally, they the delusions are still more fantastic and quite changeable. Expansive delusions may appear, but they also are limited

and constantly

in content, although they are fantastic.

The patients' judgment concerning the surroundings, except in the severer
cases, is quite

their associates, follow a daily routine,

good; they exhibit activity, converse with show a tendency to
in as far as their

employ themselves, and are quite natural,
delusions are not involved.

disturbances.

striking Nevertheless, one can detect a considerable

The memory shows no

is one of anxiety or the patients at times to attempt irritability, impelling suicide or attack their persecutors. Later, there regularly

degree of mental weakness. The emotional attitude at the onset

develops a more or less humorous attitude, manifested in witty and facetious remarks and rendering the suspicious

and

patients more pliable and approachable. Physically, besides the alcoholic tremor, there are often present more or less severe neuritic disturbances.
excitable

Course.
enforced,
is

The course

of this disease, unless abstinence

is

hallucinations

progressive. and delusions slowly subside.

With

persistent abstinence, the

In some cases

they

entirely vanish, leaving the patient in a condition But usually they persist for of simple alcoholic dementia.

may

many

years,

though steadily becoming weaker.

Numer-

ous fluctuations of the

symptoms

are characteristic; at times

the patients express some insight into their condition; they think that they are sick, but they have no idea of how they

ALCOHOLIC PARANOIA
came
into such a state,

197
also to associate

and they are able

manner with their supposed persecutors; at other times they become excitable without apparent cause,
in a friendly

complain of threatening hallucinations, and also become aggressive, but they are usually quieted without difficulty.
Diagnosis.

Alcoholic hallucinatory dementia

may

be

distinguished from some of the end stages of dementia prcecox by the history of the development of the disease, by the fact that the patients possess a greater emotional and intellectual
activity, are

more natural and approachable
humor.
if

in conduct,

and

show the

characteristic alcoholic

Furthermore, the

symptoms do not progress

total abstinence is maintained,

but rather tend to subside. There is, occasionally, a case of severe alcoholism, with pronounced catatonic symptoms. In such cases it would seem justifiable to assume that there
is

a combination of both diseases.

ALCOHOLIC PARANOIA
This form of alcoholic insanity comprises a small group of who gradually develop a delusional state

chronic alcoholics

characterized particularly by delusions of jealousy.

naturally follows excessive drinking, together with the wife's aversion to sexual intercourse, and the increasing impotency of the alcoholic, is the nucleus about which the delusions of

Symptomatology.

The family

discord

that

The tendency displayed by the alcoholic to jealousy form. lay the blame for everything upon some one else, naturally
engenders the idea that the wife is unfaithful, and that the real cause of these difficulties lies in the fondness of the
wife for other
Insignificant occurrences are regarded as important evidence of this infidelity: the assistance of some one in carrying a

men

or of the

men

for other

women.

bundle, the fondness of a friend for their children, the

198

FORMS OF MENTAL DISEASE

voluntary implication of a neighbor in a family quarrel. The frequent clanging of a car bell means that the motorman is a correspondent. A side glance from a passer on the
street, the arrival of

an unusual

letter,

and even association

with another man's wife are held as

sufficient proof of the

suspected misbehavior. Furthermore, the home and children are neglected. Patients have seen the wife enter the

apartments of a neighbor, and from noises which they have heard are sure that she was guilty of adultery. Frequently,
the children are disclaimed as those of other men, and hence must share in the abuse. Sufficient evidence of this is found
in the fact that they have different colored hair or different

The saloon keeper is implicated, if he refuses dispositions. to give them credit for liquor, or the coachman, if he hapAssociated with pens to be amiss in any of his duties.
these delusions of infidelity there
soning.

may be

delusions of poi-

These delusions of jealousy are by no means confined to married persons, but also exist in the unmarried when those
persons with

whom

mother,

sister,

they are most intimately associated, the the paramour, and sometimes the clergy
of their jealousy

become the objects

and

assaults.

These

and usually remain within the realm of possibility. The patients, however, state them coherently, oftentimes displaying considerable emotion, and, indeed, in this way they frequently convince chance acdelusions are not elaborated

quaintances of the great injustice done.
sional

There are occa-

hallucinations of hearing, when the patients hear peculiar noises about the house, such as a creaking of the
door,

whispering, rattling of the shutters,

or suspicious

sounds in another room. There may be a peculiar odor in the house, or an odd taste in the food, which is offered as proof that an effort is being made to poison them. This

ALCOHOLIC PARANOIA
incites

199

them

to nail

down

the windows and to fasten the

door in order to keep out the lovers. There is no clouding of consciousness.

In actions, the

patients usually exhibit marked weakness; they bemoan their misfortunes while submitting to the injustice. At times the actions are entirely out of accord with their delusions,

and

this is especially true in cases of long duration.

A man may live peaceably with his wife, whom he accuses of
committing adultery night after night.
very
irritable,

and

in fits of anger

Sometimes they are may be both aggressive

and

destructive.

When under
is

the influence of alcohol, the

conduct of the patients

apt to be wholly changed; then

they become aggressive and threatening and, not infrequently, make murderous assaults upon their wives or the objects of
their jealousy.

The

usually progressive. delusions seldom disappear permanently, though abstinence from alcohol often brings improvement, especially in

Course.

The

course of the disease

is

conjunction with confinement in an institution. When removed from home environment, the delusions subside and

In some patients patients are able to live very comfortably. the delusions subside and are denied; they desire to " let " bygones be bygones "; everything is past," and allow the
inference that they have been mistaken. improvement, oftentimes accompanied by
sight, influences

This apparent

an alleged

inre-

one to yield to their importunities for

lease; but regularly the return to home surroundings, with an opportunity to secure alcohol, soon leads to recurrence

of delusions.

Diagnosis.

It is often difficult to distinguish the delu-

sions of infidelity expressed

by the patient from actual
of the alcoholic freof

occurrences and facts.

The conduct

quently results in

an actual and permanent estrangement

200
the

FORMS OF MENTAL DISEASE

man and

wife,

adultery.

One must

which naturally smooths the way for rely in his judgment upon the grounds
patient.

for jealousy offered

by the

The

positiveness with

which the patient draws
data,

his conclusions

from

insignificant

and the conviction with which he applies these to others, and finally the occasional relation of strange condoubt as to the delusional origin Indeed, under some circumstances we can come to the conclusion that a jealousy which appears to be justified by real circumstances, nevertheless, on account
clusions should leave little of the ideas of jealousy. of its peculiar basis, must be regarded as morbid. This is especially clear when we observe how the patient disregards,
real, open adultery of the wife, while the delusion leads to passionate outbreaks. Delusions of infidelity may occur in the psychoses of the period of involution and occasionally also in dementia prsecox. In

with unconcern, the

general, the delusions are less apt to be fantastic in the alco-

and there are lacking the physical sensations, the hallucinations, and the nocturnal experiences which are
holic psychosis,

encountered in the other psychoses. In addition to this, there is a striking contrast between the subsidence of the

symptoms, the weakness of will shown by the alcoholic upon enforced abstinence, and his brutality and animosity when unrestrained. This psychosis is differentiated from paranoia

by the lack of a stable systemization of the delusions and by the symptoms of chronic alcoholism.
Treatment.

In these cases the treatment

is

confined to

enforced abstinence and careful watching or confinement in

an

institution to prevent assaults.

ALCOHOLIC PARESIS
This psychosis represents in the majority of cases a simple combination of the symptoms of chronic alcoholism with

ALCOHOLIC PSEUDOPARESIS
those of paresis.
There*
is

201

added to the defective memory

the expansive delusions and the emotional deterioration of paresis, the hallucinations and delusions of infidelity of the
alcoholic; while the speech disorder of the paretic
is

accom-

panied by the tremor and neuritic disturbances of the alcoholic. Epileptiform attacks also are particularly numerous.
Usually the signs of alcoholism have existed for some time before the paretic symptoms develop. On the other hand,
the
initial

that the alcoholic

symptoms may lead to such symptoms develop.

excessive drinking

ALCOHOL PSEUDOPARESIS
There are included here severe cases of alcoholic hallucinatory dementia with more or less pronounced signs of Korssakow's psychosis, in which physical symptoms predominate,
as,

tremor, speech disorder, ataxia, paralyses,

These cases are disrigid pupils, and paralytic attacks. tinguished from true paresis by the history of their development, the predominance of the polyneuritic symptoms, the active hallucinations, and the more prolonged course, which leads to a simple alcoholic dementia and not to the absolute dementia and death that characterizes paresis.

B.

MORPHINISM
of

THE

extensive use

and abuse

morphin

for its alluring

effects place it

second only to alcohol in the production of

mental and physical wrecks.
intolerance of pain among people of this age, together with the laxity of the physicians in disEtiology.

The

pensing analgesics, accounts in part for the extensive use of this drug. Being an expensive drug, its victims are
limited to the better classes.

the patients are those
effects

who

Considerably over one-half of are best acquainted with its ill

At physicians, dentists, and professional nurses. least one-half of these patients are men. On the Continent
it is

claimed that seventy-five per cent, are men. An important etiological factor is the defective constitu-

tional basis, evidences of

which in very many cases are

earlier

manifested by various neuroses, as hysteria.
free

Individuals

from

this hereditary taint usually

succumb to the drug

employment in persistent painful affecas neuralgia, sciatica, rheumatism, headache, dystions,
menorrhcea, and different forms of colic. The pleasurable feeling and the mental stimulus which supplement the analgesic effects are here the cause of its continuance. The

after its continued

majority of cases develop between the ages of twenty-five
to forty years.

In animals to which morphin had been administered for a prolonged period, Nissl has
Pathological Anatomy.

demonstrated a shrinkage of cortical neurones with an
increase of the neuroglia.
202

MORPHINISM
Symptomatology.
Acute Morphin Intoxication.

203

The

physiological action of morphin is to first produce an acceleration and excitation of the process of comprehen-

sion

and a psychomotor retardation, which
in the

later passes into

a befogged state, with changing fantastic hallucinations and

an intense weariness

psychomotor functions.

Then

ensues a quiet, pleasurable feeling, which acts as one of the strongest enticements for the habitue. For him it also pro-

duces a necessary stimulus for mental work, which cannot be accomplished by the exercise of the will power alone.

There develops a metallic taste in the mouth, and sometimes
rumbling in the bowels. Fortunately the drug fails to produce these pleasurable effects for all, owing to idiosyncrasies.

Many

after its exhibition suffer

in the head,

general feeling of discomfort,

from a disagreeable fulness nausea, and

Following the intoxication there is apt to be headache, profuse perspiration, and diminution in all of
colicky pains.

In the prolonged use of acute intoxication disappear, and the morphin individual obtains only the exhilarating and the quieting
the effects of
effects,,

the secretions of the body. Chronic Morphin Intoxication.

which aid in endurance of annoyance incident to
his

his

work or

home

life.

The

beneficial effects of this

drug diminish with usage, and soon necessitate increased dosage, which may, in time, reach from thirty to fifty grains

must also be increased. The character of the symptoms and the time of their appearance depend mostly upon the individual constitution and its powers of resistance. Some continue addicted to
daily.

The frequency

of the doses

morphin throughout life without pronounced ill effect; others succumb in the course of a few months. In these the memory weakens, and the capacity for mental application diminishes. Difficult and exhausting work becomes impossible without

204
its

FORMS OF MENTAL DISEASE
administration.

Consequently the patients are either in a condition of exhilaration, stupidity, or nervous irritability,

none

of

which are compatible with mental work.
:

Emotionally, these patients exhibit many variations they are sometimes dejected, irritable, cross, hypochondriacal;

sometimes confidential, over-nice, with pronounced affectation;

and occasionally anxious, there is a pronounced change
in

especially at night. Morally, of character, noticeable esirresistible

pecially
willingly

reference

to

their

habit.

They

submit to

all sorts of

depraved means in order to

secure the drug. Finally all idea of personal responsibility vanishes. The home and the business suffer alike, and they
fall

into a state of apathy

and

indolence, with

will

power and energy. They are careless and the personal appearance. In actions they are apt to be sleepy during the day, and active and restless at night, reading, busying themselves about foolish trifles, and talk-

an absence of about the dress

and obstinate

ing incessantly. They are also disagreeable, faultfinding, to the extreme. Very many of them become

addicted to alcohol, and other drug habits. The patients lie Physically, the sleep is much disturbed. awake for hours, their minds busied with all sorts of fantastic ideas,

sometimes accompanied by genuine hallucina-

tions of sight. Disturbances of sensibility are usually present, such as parsesthesias and hypersesthesias, especially

about the heart, the intestines, and the bladder. There is usually an increase of the tendon reflexes. The movements
are uncertain, sionally there

tremulous,
is

and sometimes

ataxic.

Occa-

difficulty in speech,

also paresis of eye

muscles (double vision and defective accommodation). The
general nutrition suffers, and there is loss of weight. The skin is flabby and dry, due in part to the absence of normal
secretions.

The

appetite, especially for meat,

fails,

though

MORPHINISM
sometimes there
is

205

mouth
there
is

creates unusual thirst.

a ravenous appetite. Dryness of the In the circulatory system

ringing in the ears,

noticed palpitation, and slow, irregular pulse. The numbness, vertigo, and syncope, as well

as the profuse perspiration to vasomotor disturbances.

and shivering, are attributable The lack of sexual desires and

impotence are prominent symptoms; in women there is amenorrhcea and sterility. The ensemble of these symptoms
creates the picture of premature senility.

Abstinence Symptoms. The abrupt withdrawal of morin individuals who are addicted to large doses produces phin
in the course of a

few hours a characteristic train of symp-

abstinence symptoms. These, according to Marme, are due to the action of oxydimorphin. The withdrawal even in milder cases is always attended with more
called
less disturbance. The patients become tremulous and uneasy, experience a tickling sensation in the nose and

toms

or

begin to sneeze;

feel oppressed,

complain of paraesthesias of
sleepless.

different parts of the body,

and are

The adminis-

tration of hypnotics, especially chloral, at this time, only increases the excitement and aids in bringing about a
delirious condition with hallucinations
sion.

and dreamy confu-

In spite of precaution, however, a condition very similar to delirium tremens may appear. This condition
but a few hours, or at most a few days. Occasionally there appears a condition of dazedness, with hallucinations
lasts

and convulsive movements.

involuntary movements, the diaphragm, paresis of the muscles of accommodation, tenesmus, paleness and flushing, vomiting, palpitation of the

Physically, the patients display twitchings of the limbs, spasm of

heart, fainting and collapse with heart failure, which is sometimes fatal. The secretion of saliva and perspiration, which during the ingestion of morphin has been diminished,

206

FORMS OF MENTAL DISEASE

now becomes excessive, and there is colliquative diarrhoea. Albumen is usually present in the urine. The duration and
symptoms depend upon the constitution of the patient, the duration of the habit, and the size of the habitual dose. The symptoms disappear gradually, except
intensity of the

where they may vanish rapidly after a In the course of a few days, perhaps weeks, prolonged sleep. the patients begin to sleep and develop an appetite, but
in the lighter cases,

from

this point convalescence progresses very slowly.

The rapidity with which the symptoms of Course. chronic morphinism develop varies with the power of resistance of the individual and the quantity of morphin
ingested; in some cases it requires a few months, in others The duration also varies; some die within several years.

a year of inanition, heart
live for

failure, or in collapse,

while others
doses.

many years
The

in spite of large

and increasing

Diagnosis. may be recognized by the varying emotional attitude; periods of mental -freshness and unusual energy with a feeling of well-being, alternating with
disease

great weariness, stupidity, dejection, and irritability, and furthermore by the physical signs the loss of sexual power,
:

anorexia, myosis, and general muscular weakness, amounting in some cases almost to paresis. Scars from the hypo-

dermic injections should always be looked

for.

The

surest

means

of diagnosis

is

seclusion or close surveillance for a

week, during which time the demand for the drug or some abstinence symptoms will appear.
Prognosis.

The prognosis

is

always very serious.

Less

than ten per cent, recover permanently; relapses are the A few cases die from overdoses of the drug. The greater danger lies in cardiac weakness, which may lead to sudden collapse and fatal termination. The drug may be withdrawn with the proper precautions and the patients
rule.

MORPHINISM
suffer

207

no ill-effects. Often, when the patients do not reinto morphinism, they revert to substitutes, of which lapse the most important are cocain, alcohol, chloroform, ether,

and

chloral.

The treatment

is

preeminently unsuccessful in
is

those with strong neuropathic tendencies. The only successful method of treatment Treatment.

complete abstinence.

For

this

isolation in a reputable institution.

purpose the first requisite is This method of treat-

ment, however, cannot be safely undertaken in all cases, and especially where conditions of physical weakness are
present, also during pregnancy, acute and severe chronic There are two methods of withdrawal, the diseases.

gradual and the rapid, the latter of which requires the greatest skill and is by far the most efficacious. The former
involves

much time and patience, and is apt
traits

to create chronic

and disagreeable

which
itself.

in the

eradicate as the habit

end are as difficult to For these reasons only the

rapid method is outlined here. It is necessary that the patients be placed in bed. In mild cases the drug may be

withdrawn abruptly. Even in these the abstinence symptoms may appear. In cases where the dose has been large, the quantity is immediately reduced one-half, and after twenty-four hours to a nominal dose of one grain daily for several days, and in the course of two weeks entirely withdrawn.

During the period of withdrawal the drug

is

best

given in single daily doses in the early evening. If previously taken hypodermically, the drug should at once be

changed to administration by mouth. Abstinence symptoms occur within the first thirty-six to forty-eight hours
after the withdrawal of the drug

and demand

careful watch-

ing on the part of the physician. To guard against these and to add to the comfort of the patient, alcohol in small doses with light nutritious diet may be given. Where there

208
is

FORMS OF MENTAL DISEASE

impending collapse, faradization of the skin, injections of ether or camphor, the administration of hot coffee or hypodermic injections of strophanthus and strychnia are indiIf these fail, cated, the last of which is often essential. finds immediate relief in return to the usual dose one always

The greatest restlessness and insomnia often If unto the influence of ice packs on the head. yield The local successful, the various hypnotics may be tried.
of morphin.

pains
tion

may

also be relieved

by the application
early;
this,

of ice.
is

Purgacontra-

should be

applied

however,

by pregnancy or an acute, serious, or chronic Diarrhoea demands no special attention. Finally, disease. it requires many months, and in some cases a year, to reestablish the former mental and physical health so that
indicated

they are able to return to their old associations without
fear of relapse.
it is

Even

after being fully reestablished in

health, necessary from time to time that the patients be subjected to close surveillance to ascertain if there is a

return to the old habit.

C.

COCAINISM

COCAIN, in distinction from alcohol and morphin in its effects, is characterized by the great rapidity with which it
produces profound mental enfeeblement and physical inaniIt is of rare occurrence to encounter symptoms of tion.
cocainism alone, because of the frequency of its complicaFor this reason it is tion with alcoholism and morphinism.

draw a pure clinical picture of the disease. The conditions giving rise to cocainism are Etiology. similar to those encountered in morphinism. Most of the have a strong neuropathic basis, and many of them patients
difficult to

have previously been addicted to morphin. Early in the history of cocainism the habit arose from the substitution
in the treatment of the latter habit, but at the present time most of the patients are physicians of cocain for

morphin

or druggists.

The usual method
it

of administration is

by the

syringe, although may be taken by insufflation. Acute Cocain Intoxication. Cocain in Symptomatology. small doses produces moderate mental excitement, with a
feeling of

and

well-being, increase of pulse rate, a fall of blood pressure. Its effects in the psychomotor

warmth and

field are similar to

those of acute alcoholic intoxication: an

excitement followed by paralysis.
energetic,
feels
is

condition

The patient is active, to write, and is talkative. This impelled sooner or later followed by drowsiness. Large

doses lead to delirious states with a tendency to collapse. Nissl has found in experiments upon rabbits that in the

210

FORMS OF MENTAL DISEASE
is

but a very slight alteration in a moderate disintegration of the chromophilic granules, some staining of the achromatic substance, and a moderate increase of the glia cells.
acute intoxication there
the cortical neurones;
i.e.

Chronic Cocain Intoxication.

In one accustomed to the

prolonged use of the drug, there is a continuous mental state of nervous excitement with a flight of ideas, complete incapacity for mental work, lack of will-power, and defective memory. The patients are overenergetic, but their activity

and very productive, writing lengthy, meaningless letters, and evolving on paper impracticable schemes. They neglect their professional and home
is

planless; they are talkative

duties, also their personal appearance.

In emotional

atti-

tude there

is

a variation between exhilaration with a proof well-being and great irritability and are very apt at times to mistrust their surthe same time they exhibit more or less in-

nounced
anxiety.

feeling

roundings.

They At

difference as to the legal consequence of their acts.

The

memory becomes
paired.
Physically, the

defective

and the judgment much imis

most prominent symptom

the profound

disturbance of nutrition; the patients lose weight very rapidly, the normal expression changes, they look sleepy and tired, the skin becomes flaccid and pale. This is due
in part to the fact that the drug supplies the place of nutritious food, for which they have lost all desire, and in part

to

excessive glandular action which drain upon the body tissues. There
irritability,

makes a continuous
is

muscular weakness

and increased myotatic
muscular twitchings.
normally, and there
is

noted sometimes in the

The

pupils are dilated,

but react
In the
cir-

tremor of the tongue.

and a tendency

culatory system there is slowness of the pulse, palpitation, to faintness. In spite of increased sexual

COCAINISM
excitement, the sexual power diminishes.
turbed,

211

The

sleep

is dis-

and occasionally interrupted by

hallucinations.

may develop Upon a definite psychosis which bears close resemblance to the acute alcoholic hallucinosis.
Acute Cocain Hallucinosis.
irritability

the basis of chronic cocainism there

Following a few days of with anxiety and some restlessness, there appear

suddenly hallucinations of different senses; the patients hear threatening voices compelling them to act strangely, and see moving pictures on the wall, which are filled with
large

and small

objects.

Characteristic of the hallucina-

minute black specks moving about on a light which are mistaken for flies, mosquitoes, and other surface, tiny objects. This, according to Erlenmeyer, is an evidence
tions are the
of multiple disseminated scotoma.

Peculiar sensations in

the skin create the belief that

they are being worked upon by electricity, being thrust with needles, or that poisonous material is being thrown upon them; but most characteristic
the sensation that foreign objects are under the skin, especially at the ends of the fingers and in the palms of the
is

hands.

The muscular

the action of some poison.
are being read by

twitchings, they believe, are due to The hallucinations of hearing

make them suspicious of their surroundings.
means of some

Their thoughts

secret contrivance; they are

being spied through holes in the ceiling. Some patients become so thoroughly frightened that they attempt to kill
their

supposed persecutors,

or

in

despair

may commit

suicide.

A characteristic symptom is the silly delusions of infidelity.
Wives or These are frequently obscene in character. of receiving many husbands are accused of illicit relations, love letters, of stealthily leaving the house and neglecting
the family for immoral purposes, or of becoming

known

as

212

FORMS OF MENTAL DISEASE
In reaction to these ideas patients are

public characters. usually vindictive

and may even become
clear.

aggressive.

The consciousness remains
tion, except in rare instances

is good orientawhere the excitement is very

There

great, or immediately following fresh injections of the drug.

In emotional attitude patients are always dejected, excitable, irritable, and sometimes passionate. Occasionally they are
reserved

and

reticent concerning their delusions.

In actions

they are usually very restless and unstable, though some may appear quite orderly. In the markedly delirious conditions

which sometimes appear there is always great restlessness. Acute cocain hallucinosis develops rapidly and may run its full course within a few weeks. The symptoms increase under the influence of single doses of cocain. The rapidly
delirious state soon disappears after the complete with-

drawal of the drug, sometimes within a few days, while the delusions may remain for weeks or even months. The co-

morphinism and cocainism in the same individual, which is of common occurrence, frequently leads to a combination of the symptoms. Morphinism alone seldom produces a rapid development of pronounced mental disexistence of

turbance, unless in connection with cocainism. Acute cocain hallucinosis is differentiated from acute
alcoholic hallucinosis

greater severity of the
delusions of

by its more rapid development, the symptoms, and by the fact that the jealousy appear earlier and as an acute symp-

tom.

a single dose of cocain during the psychosis produces an exacerbation of the symptoms, while in alcoholism it has little or no effect. Finally, the sensation
effect of

The

of objects

under the skin

is

characteristic only of cocainism.

The prognosis in cocainism is unfavorable for complete recovery. The symptoms of intoxication clear up after the
withdrawal of the drug, but the power of resistance
is

pro-

COCAINISM

213

foundly affected, and few resist temptation for any great
length of time. Treatment.
is

The only

The withdrawal

in morphinism, is best. attended only by unimportant usually symptoms, such as uneasiness, a feeling of pressure in the chest, with difficulty in breathing, also palpitation of the

complete abstinence. drawal, similar to that
is

successful method The rapid method

of treatment of the with-

employed

heart,

and insomnia, and occasionally by a tendency to

faintness which it is

simulates collapse. If such emergency arises, necessary to employ stimulants, as alcohol, camphor,

The insomnia may be combated with prolonged warm baths, paraldehyde trional, and also by a
coffee, strychnia, etc.

nutritious diet.

An

essential element in successful treat-

ment is confinement in an institution, where it can be mined with certainty that the patient does not have
to the drug.

deter-

access

Prolonged treatment with the employment of

every possible means to fortify

him against relapses is an which requires patience on the part of the important factor, patient and perseverance and tact on the part of the physician.

morphinism and cocainism be withdrawn first.
If

coexist, cocain should

IV.

THYROIGENOUS PSYCHOSES

THE two

forms of psychosis arising from disturbance of

the thyroid gland are myxcedematous insanity and cretinism. They develop directly as the result of an absence of glanducretinism appearing in early childhood, and myxcedematous insanity in adolescence and later. Rightlar activity,

fully the

symptoms accompanying Graves's

disease belong in

this group,

but are not described because of their com-

paratively infrequent occurrence.

A. MYXCEDEMATOUS INSANITY

The mental disturbance

characteristic of

myxcedema

is

that of a simple progressive mental deterioration accompanied by the characteristic physical symptoms of the
disease.

is

The lack of glandular activity in the thyroid to be the exciting cause by failing to neutralize supposed or care for some toxic product of metabolism. The gland
Etiology.
in all cases
is

found atrophied or diseased.

This

is

fre-

quently the result of connective tissue increase, sometimes
of colloid degeneration, of the gland.

and

rarely of tuberculosis or syphilis

is

The onset of the mental disturbance Symptomatology. with increasing difficulty of apprehension. The gradual,

patients do not comprehend written or spoken language as well as formerly, and are unable to collect their thoughts.
It takes

them

longer to perform ordinary duties, such as
214

THYROIGENOUS PSYCHOSES

215

Memory for recent events dressing, and they also tire easily. becomes defective. The increasing difficulty in applying the mind and in performing even simple acts finally renders
them completely helpless. sciousness. At first they
no clouding of conexhibit some insight into their but later this gives way to indifference and stupidity, defects, not only in reference to themselves and their condition, but
There
is

also to their environment.

pain,

They rarely express pleasure or and very seldom give evidence of thought for themIn emotional attitude
restlessness
it is

selves or their future.
tic for

characterisfearful-

them

to be anxious, dejected,

Sometimes they develop

and at times and moderate

excite-

ment with stubbornness.
Physically,

In rare cases there

may

appear

conditions of confusion with hallucinations

and

delusions.

they present characteristic cutaneous and

nervous symptoms.

The skin becomes

thick

and

dry,

rough, inelastic, obliterating the characteristic lines of expression in the face, producing thick lips, broad nose, and

The mucous membrane is similarly involved, and the tongue is thick and unwieldy. The cutaneous change is most marked in the supraclavicular region, in the upper arms, and in the abdominal wall. The voice is changed, becoming rough and monotonous, and the speech is slow and difficult. The nervous symptoms condeforming the hand and
fingers.

headache, vertigo, fainting, convulsive spells, and a fine tremor. Finally the skin and mucous membrane
sist chiefly of

become anaemic and very sensitive to cold, menses cease, and temperature becomes subnormal. The blood changes vary; sometimes there is an increase of the red corpuscles, and at other times a diminution. Course. The psychosis is of gradual onset, and unless treatment is applied, progresses to advanced appropriate deterioration, extreme physical weakness, and profound dis-

216

FORMS OF MENTAL DISEASE

turbance of nutrition, the disease terminating fatally through the intervention of some intercurrent disease. Occasionally
there are intermissions, and in a few cases marked improvement occurs in spite of the absence of treatment.

Treatment.
sheep,

The administration of beginning at one and one-half

dried thyroids of the grains, one to three

times daily,
disease.

be regarded as a specific remedy in this The dose is gradually increased, guarding carefully

may

against intoxication symptoms, indicated by headache, dizziThe improvement beness, and irregular cardiac action.

comes evident within a week and increases very rapidly. The patients become active and show an interest in themselves and surroundings; they improve in memory and in
judgment.
rapidity.

The physical symptoms improve with equal In the most successful cases the patients appear
persists for

quite well at the end of
tude, which

two months, except for some lassia long time. Not all cases recover

through medication;
difficult to ascertain

the

number

of unsuccessful cases is

at present.

Relapses

may

occur.

B. CRETINISM
Cretinism
is

characterized

by a more or

less

high-grade

defective mental development, associated with loss of function of the thyroid,

and accompanied by
is

definite physical

symptoms.
Etiology.

The

disease

mostly endemic in mountain-

ous regions.

In Europe the cases are most numerous in

the Alps and Pyrenees; in America, in Vermont. Sporadic cases occur as the result of congenital absence of the gland
or its atrophy during or following a fever, or in connection with goitre. The disease arises from an organic infectious material, and is in some way associated with disease of the

parathyroid gland.

It is

unknown whether

this infectious

THYROIGENOUS PSYCHOSES
organism
is

217

the cause of an atrophy, a non-development, or disease of these glands, in this way producing a failure of

mental development;

or whether

action of the organism or its Other important factors are defective neuropathic basis

due to the direct toxin upon the nervous system.
it

is

and

unhygienic surroundings.

The morbid anatomy is still Pathological Anatomy. doubtful. Asymmetries and dilatation of the ventricles of
the brain and atrophy have been found, also hyperostosis of the cranium. The cortical neurones are deficient in num-

ber and processes, and are of the stunted globose form peculiar to idiocy and other forms of defective development. The symptoms of the disease are first Symptomatology.
noticed during the first and second years, except in a few cases where the children are born goitrous. At that time

they appear
are slow
creases

dull, stupid, indifferent, sleepy, and unable to care for themselves; have not learned to walk or talk, and

and awkward in their movements. The gland inin size from the sixth to twelfth year in three-fourths
it

Mentally, the to develop, presenting the symptoms of impatients becility;^ they are dull, stupid, incapable of apprehending or
diminishes.
fail

of the cases; in the remaining

of elaborating impressions, presenting

about the capacity of

a five-year-old child.
matic,

They

are rather indifferent

and phlegany

and quite incapable

of applying themselves to

work.

A few cases present a condition of extreme stupidity.
life,

Their condition remains unchanged throughout

except

as interrupted by short periods of excitement, similar to those occurring in idiocy. This condition may form a basis
for the

development of other psychoses, especially manic-

depressive insanity.
Physically, the long bones fail to develop in length, instead,

becoming thicker.

The head

is large,

and the neck

218
short

FORMS OF MENTAL DISEASE
and
thick.

The nose

nent, the skin is The especially in the neck, hanging dependent in folds. broad face, with heavy cheeks and eyelids, with thick lips and broad short nose, presents a very characteristic picture.

broad, and the ears are promithickened as if padded, and in places,
is

and pudgy. The tongue is thick and clumsy in its movements. The hair is scanty, and dentition The speech consists of inarticuis late and the teeth poor. late sounds, which are loud, coarse, slurring, and stammerThe movements are unwieldy, the gait slow and cuming. bersome. Convulsions are rare. The sexual organs develop slowly, and in severe cases remain entirely undeveloped.

The limbs

are large

Patients have

little

power

of resistance, readily

succumbing

to intercurrent diseases.

The hygienic surroundings must be imwith special attention to drinking water. Many proved observers agree that it is advisable as a prophylactic measure
Treatment.
to send children

and

families with cretinoid tendencies to

the high mountains, which may bring about a complete recovery in children who already show some signs of disease.

Potassium iodide in small doses seems to be

beneficial.

According to recent observation the administration of desiccated thyroid, if given early, may aid in preventing the

development of the disease.

After an extended duration the

same drug may improve some of the physical symptoms, thickness of the skin and amenorrhoea, but the mental

symptoms cannot be

altered.

V.

DEMENTIA PR^COX
l

DEMENTIA PR^COX

is

the

name

provisionally applied to

a large group of cases which are characterized in common by a pronounced tendency to mental deterioration of varying
grades. The disease apparently develops on the basis of a severe disease process in the cerebral cortex, but whether

always the same is by no means certain. Dementia fortunately does not occur in all cases, but it is so prominent a feature that the name dementia prsecox is
the process
is

best retained until the
Etiology.

symptom group is better understood.
is

one of the most prominent, comprising from fourteen to thirty per cent, of all admisdisease
sions to insane institutions.

The

As the name

indicates,
2

it is

More than sixty per cent. of the life. cases appear before the twenty-fifth year. This, however, varies in the different forms; in hebephrenia almost threea disease of early
1

Finzie Vedrani, Rivista sperim.de freniatria,
;

XXV,

1899; Chris-

Ann. me"dico-psychol. 8, 9, 43, 1899 Trcemmer, Das Jugendirresein (Dementia praecox), 1900; Serieux, Gaz. hebdomad. Mars 1901; Revue de psychiatric, Juin 1902; Jahrmaerker, Zur Frage der Dementia praecox, 1902; Meeus, Bull, de la soc. de me*d. ment. de Belgique, mars-sept. 1902; Masselon, Psychologic des dements precoces, 1902; Stransky,
tian,

Psych. XXIII, 1903 Bernstein, Allg. Zeitschr. f. Psych. LX, Meyer, British Medical Journal, Sept. 29, 1906. 2 In our experience in Connecticut the age of onset has been under 25 of the cases in the hebephrenic form 45 years of age in only 34
f.
;

Jahrb.

554, 1903

;

%

;

%

develop the disease under 25 years of age, in the catatonic form 38 %, and in the paranoid only 11 %. The average age of onset in all forms is from one to four years earlier in the male than in the female patients.
219

220

FORMS OF MENTAL DISEASE

fourths of the cases appear before the twenty-fifth year, in catatonia sixty-eight per cent., and in the paranoid only
forty per cent.

any way

the other hand, cases that cannot in be distinguished from hebephrenia have been ob-

On

served in patients between fifty and sixty years. The disease in the younger cases seems to take the form of a simple gradually progressive deterioration; in the somewhat later periods, it assumes the acute and subacute forms with
catatonic

symptoms while
;

still

later the

more pronounced

delusion formation appears.

Kraepelin reports that in the

|

hebephrenic form sixty-four per cent, of the cases are men, in catatonic and paranoid forms women slightly predominate but in our experience men slightly predominate in the hebephrenic and catatonic forms, while in the paranoid form
;

Defective heredity is a sixty-nine per cent, are women. very prominent factor, as it appears in about seventy per
cent, of cases reported

by Kraepelin, but
It varies

in not

fifty-two per cent, of our cases. different forms, being far more

more than somewhat in the

prominent in the paranoid

and equally
forms.

less prominent in the catatonic and hebephrenic Various physical stigmata are occasionally encountered, such as asymmetries and malformations of the skull,

ears,

and

palate,
nipples,

puerile

expression,

strabismus,

superis

numerary

general physical

weakness.

There

frequently an

earlier history of deliria

erate forms of fever, of convulsions in
ceptibility

accompanying modyouth, and great sus-

to alcohol, as well as the absence of sexual impulses and their early or unnatural development. Besides the above evidences of a faulty endowment thirty-three

per cent, of the patients previous to the onset of the disease

have been only moderately bright.
seclusiveness,
affectation,

twenty per cent, exhibit mental peculiarities from early youth up, such as
least
[

At

eccentricity,

precocious

piety,

1

DEMENTIA PILECOX
impulsiveness,

221

and moral

instability, while

seven per cent,

have always been weak-minded. In women, child-bearing seems an important factor, as twenty-four per cent, of the
female catatonics become afflicted during pregnancy, or at childbirth, but particularly the latter. This occurs in
only nine per cent, of the female hebephrenics. In ten per cent, of the cases there is a previous history of some severe acute illness, particularly typhoid and scarlet fevers/from

which time the patients have exhibited some change, as
increased
irritability,

susceptibility to

fatigue,

and im-

pairment of the full mental capacity. Head injuries precede a very small number of cases. Alcoholism, likewise,

an unimportant factor, but more than five per cent, of the male patients develop their disease while incarcerated These and the puerperal cases are particularly in prison. Pregnancy apt to develop into acute and subacute forms. favors the paranoid forms; and child-bed, the catatonic forms.
is

Pathology.

The nature

of the disease process in de-

mentia prsecox is not known, but it seems probable, judging from the clinical course, and especially in those cases where there has been rapid deterioration, that there is a definite
disease process in the brain, involving the cortical neurones. This view is further upheld by the fact that in those cases

which have been subjected to the most modern methods of research, anatomical lesions have been found which can be explained only upon such a basis. In a few cases this
is a reparable lesion, but in most cases the impairment of function is permanent and progressive. This pathological

basis finds clinical expression in the

few cases that recover and the larger number that show a permanent mental defect. The means by which these assumed changes are brought about in the nervous system are no better known than those that exist in epilepsy and idiocy. The relationship of the dis-

222

FORMS OF MENTAL DISEASE

ease to puberty, disturbances of menstruation, child-bearing, and climacterium, and the absence of every recognizable external cause, suggests first of all an autointoxication, which may be in some way related to processes in the sexual organs.

Defective heredity, which exists in such a large percentage of cases, may be presumed to create a lessened power of
resistance to the essential causes of the disease.

Symptomatology.

In the

field of

apprehension there

is

usually very little disturbance. Ordinary external impressions are correctly apprehended, the patients being able to recognize their environment and to comprehend most of what takes

Yet accurate tests show that very brief place about them. stimuli are not well apprehended. During the acute or
subacute onset of the disease, apprehension is affected, and there is some disorientation. This may also appear during
transitory stupor or excitement; but even in these conditions, and especially in the apparent stupidity and indiffer-

ence which characterize the later stages of the disease, it is surprising to see how many things in the environment are

apprehended. Indeed, it is not unusual to find that patients even notice changes in the physician's apparel, in the furNevertheless, as the disease advances and niture, etc.
deterioration appears, apprehension, as well as other mental

phenomena, becomes perceptibly impaired.

The

orientation

know where they

mostly undisturbed. Patients usually are, recognize those about them, and are
is

aware of the time. In stupor and in states of anxiety, the orientation may be considerably clouded, yet it is characteristic of dementia prsecox that, even in spite of considerable
excitement, the patients continue to apprehend well. the other hand, the delusional form of disorientation
exist (see p. 28).
is

On may

Apprehension

always more or

less distorted

by

halluci-

DEMENTIA PR^ECOX
nations^ especially in acute

223
of

and subacute development

the

Occasionally, they persist throughout entire course of the disease. They, however, tend to dis-

disease.

the

appear in the end stages, though they occasionally reappear
during exacerbations. Hallucinations of hearing are most prominent, next come hallucinations of sight and touch, the feelings of currents, of movements, and of influence.
are distressing, and result in fear; but later they do not excite much reaction, except during exacerbations.

Hallucinations at

first

Consciousness is usually clear, but in conditions of excitemeirtrand stupor there is always some clouding of consciousness.

It

is,

however,

much

less

marked than one would
happened
in the

judge from superficial observation, as the patients later are
able to give
interval.

some

details of things that

On

the other hand, there
is

is

voluntary attention, which

pronounced impairment of one of the most fundamental
is

symptoms.

The

controlling force of interest

altogether

lacking, so that the presentation which happens to be the clearest and most distinct at any given moment is an accident of passing attention, never persistent enough to occa-

In spite of the fact that the patients perceive objects about them correctly, they do not observe them closely or attempt to understand them. In
sion connected activity.
it is absolutely In the to attract the attention in any way. impossible catatonic form of dementia prsecox the presence of nega-

deep stupor and in the stage of deterioration

tivism inhibits
as

all

active attention.

This becomes evident

gradually disappears. The patients emerging from this condition are caught stealthily peeping about when unobserved, looking out of open doors or winthe

negativism

dows, and following the movements of the physician, but

224

FORMS OF MENTAL DISEASE
object
is

when an
There
is

held before

them

for observation they

stare vacantly about or close their eyes tightly.

a characteristic and progressive, but not profound, impairment of memory from the onset of the disease. Memory images formed before the onset of the disease are retained retention is good. Though with remarkable persistence,
their reproduction is increasingly more difficult, unusual stimulation or excitement may occasion the recollection

of events long since supposed to be effaced of deterioration recollection
is

not

free.

by the advance The formation of

new memory images is increasingly difficult with the advance of the disease. Memory for recent events is poor.
Events previous to the onset, especially school knowledge, may be recalled after the patients show advanced deterioration.

Some few patients keep

a careful account of the length

and elsewhere. Events and excitement are not remembered at all, during stupor or at most indistinctly. The train of thought sooner or later in the course of the
of their residence in the hospital

disease

is

acteristic looseness

profoundly disturbed by the appearance of a charand desultoriness, which has already been

described (see p. 40). One finds even in the mild cases some distractibility, a rapid transition from one thought to another

without an evident association, and interpolation of highsounding phrases. In severe cases there is genuine confusion
of thought with great incoherence and the production of new words. In cases of the catatonic form especially, we meet with

evidences of stereotypy; the patients cling to one idea, which they repeat over and over again. Besides, there is occasionally

noticed a tendency to rhyme or repeat senseless sounds. In judgment there appears from the onset a progressive
defect.

culty under familiar circumstances, they

While patients are able to get along without diffifail to adapt them-

DEMENTIA PILECOX
selves to

225

new

/

the meaning tional. This condition of defective judgment becomes the The patients bebasis for the development of delusions. lieve that they are the objects of persecution, and they may

to their inability to grasp of their surroundings, their actions are irraconditions.

Owing

/

have delusions of reference and
of

self-accusation.

The lack

judgment becomes still more apparent in the silliness At first the delusions may be rather of their delusions. but later they tend to change their content frestable,
quently, adding new elements suggested by the environment. Even relatively persistent delusions are constantly taking on new meanings. Furthermore, the delusions, which at first are of a depressive nature, later may become exIn most cases the wealth of delupansive and grandiose.
sions so apparent at first gradually disappears. delusions may be retained with further elaboration

few from time to time, but they are usually expressed only at random. During exacerbations the former delusions, whether depres-

A

sive or expansive,

may

again come to the foreground.
there

In
the

paranoid forms, however, persists beginning a great wealth of delusions, but these become

the

from

more and more incoherent.
disturbance of tb^jemoiLonaL^eld
is

another of the

/The

characteristic

and fundamental symptoms.

There

is

a pro-

gressive,

tionaJLlife.

more or less high-grade, deterioration of the emoThe lack of interest in the surroundings already

spoken of in connection with the attention may be regarded as one phase of the general emotional deterioration. Very
often
it is

this

symptom which

first calls

attention to

the^
*

approaching disease. Parents and friends notice that there is a change in the disposition, a laxity in morals, a disregard
for formerly cherished ideas, a lack of affection

toward

rela-

L

tives

and

friends,

an absence

of their

accustomed sympathy,

226

FORMS OF MENTAL DISEASE

and above all an unnatural satisfaction with their own ideas and behavior. They fail to exhibit the usual pleasure
in their

employment.

As the disease progresses the absence of emotion becomes more marked. The patients express neither joy nor sorrow,
have neither desire nor fears, but

from one day to another quite unconcerned and apathetic, sometimes silently gazing
live

into the distance, at others regarding their surroundings with a vacant stare. They are indifferent as to their personal appearance, submit stupidly to uncomfortable posi-

and even prodding with a needle may not excite a reaction. Food, however, continues to attract them until
tions,

Indeed, it is not unusual to see these patients go through the pockets and bundles of their friends for delicacies, without expressing a sign of recdeterioration
is

far advanced.

ognition.

This condition of stupid indifference
short periods of irritability.

may be

interrupted by Early in the disease, and especially during an acute and subacute development, the emotional attitude may be one
of depression

and anxiety.

This

may

later give

way

to

moderate elation and happiness. The latter, however, in a few instances prevails from the onset. Yet emotional
deterioration remains a fundamental

symptom.
found
dis-

Parallel with the emotional disturbances are

turbances of conduct, of which the most fundamental is the progressive disappearance of voluntary activity. One
of the first

symptomToTthe
is

disease

may

be the loss of that

activity

which

his duties

and

sit

He may neglect peculiar to the patient. for the greater part of the day, unoccupied

though capable of doing good work if persistently encouraged. Besides this characteristic inactivity, there may appear a
tendency to impulsive

dow lights,

acts. The patients break out wintear their clothing into strips, leap into the water,

DEMENTIA PILECOX

227

break furniture, throw dishes on the floor, or injure fellowpatients, all of which seems done without a definite motive.

These states usually pass off very quickly, though in some this tendency may be more marked for a period of a few
days.
inability to control the impulses is also present in the stuporous conditions, and especially in the catatonic form of

The

dementia prsecox. Here each natural impulse is seemingly met and overcome by an opposing impulse, giving rise to
actions directly opposite to the ones desired. In this condition, which is called negativism, the patients resist everyis done for them, such as dressing and undressing, refuse to eat when food is placed before them, to open they their mouth or eyes when requested, or to move in any direc-

thing that

tion.

In extreme conditions there

may even

be retention

of urine

and

feces.

intensity at different times. patients suddenly relieved of

This condition varies considerably in It is not unusual to see the
it,

assume

their former activity,

after

talking freely and attending to their own needs, and again an interval of a few hours or days relapse gradually into the negativistic state.

^another condition is produced by the repeated recurrence of the same impulse, giving rise to a great variety
Still

movements and expressions. The verbigerations and mannerisms of the catatonic are explained in this way. The patients repeat for hours similar expressions,
of stereotyped

utter

monotonous grunts, tread the floor in the same spot, dress, undress, and eat in a peculiar and constrained manner.

it is

While these symptoms vary considerably in individual cases, unusual not to find at least some of them present in
every case.

Frequently also hypersuggestibility of the will and automatism are present, particularly in the stage of deterioration.

228

FORMS OF MENTAL DISEASE
show

The

patients are not only very pliable, but they may echolalia or echopraxia for longer or shorter periods.

Some

patients, however, never show these symptoms at any time during the disease.

fundamental symptoms of the disease is the discrepancy or lack of uniformity between the emotional attitude and the content of thought. Thus, patients laugh and cry without apparent reason; they cheerfully refer to
of the

One

their attempts at suicide, and exhibit great anxiety or outIndeed bursts of passion upon the slightest provocation.

between the ideation and the emotional attitude gives one the impression of childishness. The whole conduct shows many similar incongruities; the discrepancy
this discrepancy

seen between the feelings and the facial expression is called paramimia; such as, weeping on cheerful occasions, and

laughing

when sorrow should
and crying,
etc.

prevail; also the combination

There are many other symptoms, as mannerisms, eccentricities, and perhaps also the confusion of speech and the use of neologisms, which may be explained on the basis of a disruption of the natural connecof laughing
loss of

tion between the processes of thought, feeling, and will. This spontaneity frequently leads to the idea that the pa-

tients are being controlled by the will of another. They feel that their acts are not their own, but that they are compelled to do unnatural things. Hence some patients come to

believe that they are being hypnotized.

capacity for employment's seriously impaired. The patients may be trained to do a certain amount of routine

The

A fail when given something new. few patients display artistic abilities, as, for instance, in drawing or in music, but their efforts are characterized by eccentricities. They may show some technical skill, but their
work, but they utterly
productions exhibit the absence of the finer aesthetic feelings.

DEMENTIA PILECOX
Physical Symptoms. epileptiform nature, are
,

229

Attacks either of a syncppal or an among the most important physical

symptoms.

These

may

of the disease or but once.

occur frequently during the course They rarely involve alone single

groups of muscles, or are apoplectiform in nature followed

by more or less prolonged paralyses. Occasionally these attacks represent the first symptom of the disease. They occur in about eighteen per cent, of the cases and are twice
as frequent among women as among men. In addition, There is still another hysterical attacks are also observed.

type of convulsive movement, involving the muscles of the
eye and speech, which is both characteristic and of frequent occurrence in dementia prsecox. Some of these movements

correspond exactly to the movements of expression; wrinkling of the eyebrow, distortion of the mouth, rolling the eyes, and those other facial movements which are characterized
as grimacing.

These movements remind one of choreic

There

movements and are quite independent of ideas and feelings. may be associated with them smacking of the lips, clucking the tongue, sudden grunting, sniffing, and coughing. Furthermore, in the lips we observe very rapid rhythmical movernents. More often there exists a peculiar choreiform movement of the mouth which may be described as an athetoid ataxia.

There is usually an increase of the deep reflexes as well as of the mechanical irritability of the muscles and nerves.

The

pupils are often dilated, particularly in conditions of excitement, and are occasionally unequal. Not infrequently
to

sensibility

as cyanosis,

occur in

all

Vasomotor changes, pain is diminished. circumscribed edema, and dermograph, may stages of the disease, but are most often met in
Excessive perspiration
is

the stuporous states.
present.

is

sometimes

The

secretion of saliva

frequently increased.

230

FORMS OF MENTAL DISEASE

The

heart's activity varies, sometimes being slowed, more often accelerated, but also sometimes irregular and weak. The menses usually cease or are irregular. The body tem-

perature is often subnormal. In many cases there has been detected a diffuse enlargement of the glands, which

sometimes undergo atrophy just before the onset of the disease. Exophthalmic goitre and tremor are sometimes
present.
is

Anemia and
apt to be
little

chlorosis are frequently observed.

The

disturbed during the developmental sleep stage, at which time there is also anorexia and the patients tend
to take

much

nourishment; but later in the course of the disease the taking of nourishment may vary from absolute
of food

refusal

to

extreme gluttony.

usually falls at the onset of the disease, degree, even in spite of the fact that the patients are taking a sufficient quantity of nourishment. On the other

The body weight and often to a marked

hand, the weight usually rises later and not infrequently rapidly and to a marked degree.

group of cases comprising dementia divided into three smaller groups the hebephrenic, prsecox is the catatonic, and the paranoid, each of which differs someClinically, the large
:

what

in the grouping, prominence,

and course

of the funda-

mental symptoms.

HEBEPHRENIC FORM
The hebephrenic form
dementia prsecox is charactergradual or subacute development of a simple more
of

ized by the or less profound mental deterioration.
of the cases of

An

acute onset

is

rare.

This form represents in our experience fifty-eight per cent,

dementia prsecox. The larger number of cases

develop under twenty-five years of age. The first symptoms may appear at the beginning of puberty. The onset may

be so insidious that the actual date cannot be placed.

Some

DEMENTIA PILECOX
of these patients

231

do not even come under the care of the

physician until years after the onset of the disease. The hebephrenic form should include a small group of
cases which gradually develop a simple hypochondriacal dementia. The prominent symptom is a constantly increas-

and mental incapacity, accompanied by all kinds of morbid sensations, which finally compel the patients to desist from any sort of activity. At the same time there develops an emotional indifference and
ing feeling of physical

general

languor

without

hallucinations

or

pronounced

delusions.

Symptomatology. Usually the patients first complain of headache and insomnia, which are soon followed by a
gradual change of disposition.
activity

They

lose their

accustomed

self-absorbed, shy, sullen, and or perhaps irritable and obstinate. They may seclusive, be rude and assertive, or perfectly indifferent. They become

and energy, becoming

careless of their obligations, thoughtless,

and unbalanced.

They accomplish nothing, but rather

sit

about unemployed,

apparently brooding, or they leave their work to go to bed, Others, lying there for weeks without evident reason.
instead
x>f

this inaction, exhibit
effort is impossible.

a marked

restlessness,

and

continuous They leave their work, stroll about or travel from place to place, especially at night. Others, with increased sexual passion, indulge in illicit and

promiscuous intercourse. During this period, which

may extend through

several

months, remissions are common, when for a short time the patients improve greatly and may even appear natural. This period, on the other hand, may rather be characterized

by alternating periods

of depression

ing severity. Women disease during the menses.

and elation of increasusually show premonitions of the

232

FORMS OF MENTAL DISEASE
is

Sometimes the onset
depression.

characterized by a period of

marked

The patients become apprehensive, dejected, and reserved. They are troubled with thoughts of sad, death, and sometimes suddenly attempt suicide, often
in a peculiar

are usually hypochondriacs, and complain of nervousness and weakness; they search quack medical literature and frequently ascribe their troubles

manner.

They

There is also a mistrust of the environment and a feeling that they are being watched, imposed upon, or badly treated. But most striking is the emotional indifference with which the patients express and defend their morbid ideas.

to former masturbation.

Many

cases develop

no

further.

The more

severe cases

at this time begin to show hallucinations, especially of hearThe patients are annoyed by ing, and less often of sight.

strange noises, unintelligible voices, unfavorable comments upon their personal appearance; they hear threats and
imprecations, music

and

singing, telephone messages,

and

commands from God.
crosses

They may

also see heavenly visions,

on the wall, dead relatives, frightful accidents, and deathbed scenes. Occasionally they smell various odors,
especially illuminating gas

and sulphur.

beperience various hypersesthesias lieve that the head is double, that the throat or nose is

They may which lead them to

ex-

occluded, that the genitals are being consumed, or that the bowels are all bound together.

At the same time delusions become a prominent part of the picture and are mostly of a depressive character. The patients believe themselves guilty of some crime, accuse themselves of being murderers, claim that
unfit to live,
its

they are

lost,

are

damned,

have practised self-abuse, and can
ill

never recover from

effects. They suspect their surdetect poison in the food, are being worked upon roundings,

DEMENTIA PILECOX
others, their thoughts are not their own, friends turned against them and are trying to do them harm,

233

by

have

some them constantly, and they are being harwatching assed by various agencies. Women are followed by men who would ravish them. Later in the course of the disease, and occasionally from the onset^ the delusions are expansive;
one
is

the patients then regard themselves as prominent individuals the President, the Son of God, the Creator, the possessor of
:

They converse with God, are the Saviours of and possess all knowledge. Some patients are conmen, trolled by sexual ideas, fancying perhaps that they are bethe universe.

trothed to prominent individuals. Men believe themselves possessed of many wives, or regard themselves as the center
of attraction for all

women.
fabri-

These delusions

may be augmented by numerous

cations; the patients claiming that they have been President for a century, chief commandant in various engage-

ments, have been knighted, that they have been in heaven, have gained possession of the key of hell, have just returned

from a

visit to

Mars.

These fabrications, together with the

delusions, gradually recede to the background.

At

first

they become

less

numerous,

less fantastic,

then incoherent,

and

still

more

scanty, until finally, in the

advanced stages

of the disease, there remain only incoherent residuals of

former delusions which
elicited,

never be expressed except when or during excitement.

may

Some
first

insight into their condition is often expressed at

by the patients. They are conscious that a change has come over them, and often complain that the head feels strange, benumbed, or empty. These ideas may be expressed in connection with somatic delusions, when they will claim
that the brain
is

rotting, the

different in every

way, or are very

memory failing, that they are much confused. But

234

FORMS OF MENTAL DISEASE

even this scanty insight gradually disappears as the disease
progresses.

is

In those forms of the disease which develop slowly there at first neither clouding of consciousness nor disturbance In the acute or subacute onset, cloudiness
unite in the clinical picture hallucinations and delusions, anxiety
disorientation

of orientation.

and general
with

may

pronounced
restlessness,

of thought. The patients mistake persons, do not appreciate where they are, and are unable to record passing events. Physicians are regarded as enemies trying to kill them, working upon them with
electricity, etc.

and

and incoherence

are confined in a prison for some grave offence, or are among the heavenly hosts, surrounded by

They

saints.

The
at
first

train of thought in the gradually developing cases is very little disturbed, the content of speech being both

coherent and relevant; but later in the disease and with progressive deterioration there develops the characteristic
of thought and desultoriness, often combined with the use of neologisms and embellishments.

looseness

The memory at first suffers only moderately. Memory of and the chronological order of events is well re* tained for a long time. Some of the patients are able to
earlier life

with surprising accuracy the exact definitions in geography and many historical events almost word for word, as committed to memory years before. But with the progtell

ress of the disease there is

an increasing impoverishment

impressibility of memory is retained, but the patients fail to make use of it, because there is a total lack of interest. Without this there is no incentive for observation

of the store of ideas.

The

what
there

is
is

and thought, and they fail to observe on about them. As the disease progresses, going increasing limitation of thought. For this same

DEMENTIA PRJECOX

235

reason past experiences are seldom recalled, and so finally fade from memory; though it is not unusual for patients,
in reaction to unusual stimulation, to recall events that

seemed to have

entirely passed

from them.

The defect in judgment appears early, develops rapidly, and becomes profound. This may not be evident while
the patient is confined at home, or during the early part of the residence in an institution, as long as his thought is employed with familiar facts, and his range for action limited.
It

becomes apparent, however, when he leaves the trodden path and attempts to adapt himself to new circumstances. He is unable to reason, to perform mental work, to recog-

nize contradiction, or to overcome obstacles. can also be seen in his tendency to formulate
senseless, incoherent delusions.

The defect and hold to

In emotional attitude the most prominent and permanent Whenfeature is that of emotional dulness and indifference.
ever we find emotional activity it is increasingly self-centered. At first there is usually more or less depression, with anxiety,
peevishness, and often irritability. Exaggerated expressions of religious feelings are apt to be prominent, the patients

being devout, praying frequently, reading their testaments, at first apparently in the spirit of penitence, but later because they are led by God or ordained to do some special work. The sexual feelings very often play a prominent role, particularly in those who have been addicted to the
habit of masturbation.
matters,

Thought may center about sexual
literature,

when they enjoy obscene

write long

letters to acquaintances, and give expression to their lascivious feelings, masturbate, and solicit intercourse. Female patients are more apt to associate with their own

sex.

in the course of the disease.

In both sexes these feelings are apt to disappear later Later in the disease the de-

236

FORMS OF MENTAL DISEASE

lusions, both expansive and hypochondriacal, are expressed without display of emotion. Patients fail to express emotion at the loss of friends, at the visits of relatives, or at an un-

usual supply of food, fruit, or candies. They live a very empty life, devoid of any cares or anxieties, and without thought for the future.

In conduct and behavior, the most characteristic sympthat of childish silliness and senseless laughter. The voluntary activity is inconsistent and lacks independence.

tom

is

At one moment patients
pearance, perform such as prowling about

are increasingly headstrong, at the
of outlandish

next as supremely tractable.
all sorts
all

They neglect their personal apand foolish deeds,

night, setting fire to buildings,

throwing stones to break windows, and travelling about without evident purpose. They may even run away and secrete
themselves, or as unexpectedly
forget
their obligations,

demand some one in marriage,
finally

and

are completely inca-

pable of

continued and

young man was
voices of evil

comprehensive employment. A found throwing stones into trees because the A student ran from his spirits annoyed him.

mates to a graveyard and covered himself with leaves in
order to obtain aid in committing his ivy oration. A girl of fourteen attempted to stab her lover, believing him to be
unfaithful.

A

young married woman

solicited intercourse

among gentlemen friends, even bringing them to her
for that purpose in the presence of her

home

husband and

children.

The

patients are very often seen to converse with themselves, sometimes aloud, while associated with this there is

almost always

silly

prominent and symptom. It is unrestrained, on all occasions without the least provocation, and appears
altogether without emotional significance. Besides these actions, mannerisms, such as peculiarities of speech and
is

laughter. characteristic

This

silly

laughter

is

a very

DEMENTIA PILECOX

237

movements, eating and walking, are often present. A few of the mannerisms characteristic of the catatonic may prevail: echolalia, echopraxia, stereotyped expressions and

movements.

The speech presents peculiarities indicative of looseness Their remarks may of thought and confusion of ideas.
be
artificial,

containing

many

stilted phrases, stale witti-

The incisms, foreign expressions, and obsolete words. coherence of thought becomes most evident in their long drawn out sentences, in which there is total disregard for grammatical structure. The structure changes frequently, and there are many senseless interpolations. All this becomes even more apparent in their letters, which are verbose with frequent repetitions, while the handwriting is characterized by a marked lack or a superfluity of punctuation marks, shading of letters,

and copious underlining.

During the onset of the disease Physical Symptoms. the condition of general nutrition suffers. There is a loss
of weight,
is

and some patients even become emaciated.

The

appetite strained by

Patients eat sparingly or not at all, repoor. suspicion and fear, or because they are so directed

by God.' The sleep also is much disturbed, both by anxiety and distressing dreams. The pupils are occasionally dilated. The tendon reflexes may be exaggerated, and vasomotor disturbances may be present. The skin loses its normal healthy appearance, becoming dry and flaccid. The menses Later in the course of the disease cease or become irregular. the appetite returns and often becomes excessive. At this time the weight often rises rapidly, and the emaciated condition is frequently replaced by great corpulence. The menses also reappear and remain normal, and the evidences of muscular and nervous irritability disappear. Course. The course of the disease in the hebephrenic

238

FORMS OF MENTAL DISEASE
is

form

characterized by

all sorts

of variations.

Suitable

treatment during the active stages at the onset usually

But there develops later produces some improvement. a condition of uniform dementia, which may be permanent,
or interrupted by repeated exacerbations. Occasionally there develop conditions of pronounced excitement with

mischievousness, talkativeness, clownish behavior, laughing, giggling, a tendency to sexual acts, and senseless wandering

about.

In other cases there develop profound clouding,

with impulsiveness, greater incoherence of thought, dancing, smearing, destructiveness, and assaults. These conditions
are usually of short duration. They may recur suddenly and without warning. The degree of mental defect increases from year to year, more especially following the transitory

periods of excitement. Of the cases that are admitted to insane institutions, about seventy-five per cent, reach a profound degree of deteriare dull, indolent, apathetic, to apprehend the surroundings. anergic, sluggish, They remain seated for hours wherever placed, are incapable
oration.

These

patients

and

fail

of caring for themselves, are untidy, have to be dressed

and

undressed, and led to meals. At table they are slovenly, spattering and smearing themselves with food. They give
little evidence of voluntary activity. They seldom speak, are unproductive and mute; occasionally they may be seen to laugh sillily or repeat to themselves some unintelligible

but

word or

syllable.
is

Their attention
for a short time.

attracted with difficulty and held only External objects usually fail to make an

impression upon them.

prehended,

seldom

Questions are apparently uncomexciting intelligible answers. These

are usually monosyllabic

and

irrelevant.

Simple directions,
Relatives

however,

may

be correctly carried out.

and

ac-

DEMENTIA PILECOX
quaintances
historical

239

may

not be recognized.

Bits of former knowl-

edge are retained in lems in arithmetic.

many

cases for a long time, such as

and geographical facts and the ability to solve prob-

In this respect the patients often surone. One of patients was able to name the islands prise of the Pacific and give the names of their sovereigns. Another, who for two years had been mute, unable to care

my

through the day with bowed unmindful of his surroundings, recognized head, entirely a college mate, straightened up with an air of dignity, and laughed at some college jokes. In the course of time even
for himself, untidy, sitting

such

relics of
left

nothing

former mental activity disappear, and we have but the unproductive vegetative organism.

A few patients retain some remnants of mental activity,
they are quite unbalanced,
of hallucinations
silly,

but

and present the

residuals

and

delusions.

Instead of the extreme

stupidity and indolence
talkative,

some patients continue restless and an incoherent babble with silly laughter. producing

During the periods of transitory excitement these patients are very apt to be aggressive, breaking windows and attacking fellow-patients, to masturbate shamelessly, pull out their
hair,
it

and frequently show homicidal tendencies.

Usually

requires several years before the patients reach this stage In cases with an acute onset it may appear of dementia.

within a year. In about seventeen per cent, of the cases the degree of deterioration is not as far advanced. These patients, after the
subsidence of the more acute symptoms, show a certain amount of mental activity and are capable of some employ-

ment under supervision. They are oriented and have a certain amount of insight into their mental incapacity, but lack mental energy and the power of application. They
have
little interest

in the surroundings,

no care for their

240

FORMS OF MENTAL DISEASE
livelihood,

own

tented to live
to present

and no thought for the future, but are conand be cared for. In conduct they are apt
is weak and memory defective. Imporbe retained, together with school knowl-

many mannerisms.

The judgment
tant events
edge, but

may memory
is

for events subsequent to the onset of the

psychosis

very poor, while they are quite incapable of

The hallucinations and acquiring additional knowledge. delusions of the various stages of the disease for the most
part entirely disappear. While retained in a few cases, they are of little importance to the patients, rarely influencing

As in the other grades of dementia, so here, a tendency for the deterioration to increase as the patients advance in age. This is especially noticeable foltheir behavior.

there

is

lowing short periods of excitement, which are apt to be coincident with menstruation. At these times the patients

and sometimes violence, with a reappearance of former delusions and hallucinations, talkativeness, silly behavior, and incapacity for employment. The delusions are more apt to be expansive, changeable, and incoherent, but at times there may be verbigeration and repetition of single phrases. The
restlessness,

show motor

with great

irritability

actions are usually purposeless.

few of these cases leave the institution apparently recovered, but upon reaching home the patients fail to employ themselves profitably. They spend much time in reading,
evolving impractical schemes, and pondering over abstract and useless questions. Or, if employed, they show a lack
of interest, are unbalanced, and unable to advance in their Later their field of thought beprofession or occupation.

A

comes more circumscribed and their relations with the
outside world correspondingly meagre. They become seclusive and so much disinterested in intellectual work that

DEMENTIA PILECOX

241

they pass their time in purely machine-like action, engaged
in gardening or transcribing. Finally in about eight per cent, of the cases the

symptoms

of the disease entirely disappear, leaving the patients apparently

in their normal condition.

Not

all of

these cases should be

regarded as perfect recoveries, because in some instances there have been recurrences in later life, followed by deterioration.

In

still

other cases there has been a stunting of mental depatients have been unable to realize their Young men and women whose academic or

velopment. ambition.

The

collegiate courses

have been interrupted by the psychosis

find themselves unable to enter into active business or professional
life. These patients are able to care for a farm or a small business where there is little demand for in-

In this way we lose sight of the mental shipwreck following dementia prsecox, because enough mental capacity is retained to permit them to maintain the
tellectual

work.

battle of life in their chosen

narrow

field.

CATATONIC FORM (Catalonia)

The catatonic form of dementia prsecox is especially characterized by stuporous states with negativism, hypersuggestibility,

and uniform muscular

tension;

excited states

with stereotypy and impulsiveness; leading in most cases, with or without remissions, to mental deterioration. This form

comprises in our experience about eighteen per cent, of the entire group of dementia prsecox.
Pathological Anatomy. Alzheimer, in fatal cases of acute delirium which he believed belonged to catatonia,

has described profound changes in the cortical neurones of the deeper layers. The nucleus was much swollen, its

membrane

wrinkled, and the cell body shrunken, with a tendency to disappear. In the glia there was an increase of

242
fibres

FORMS OF MENTAL DISEASE
which fastened about the
cell in

a peculiar manner.

Nissl, in all prolonged cases of catatonia, has demonstrated

extensive changes in the cells, which vary considerably in degree as well as kind. Even in cases where there appeared to be no atrophy in the cortex, he found a number of cells

which had undergone degeneration. In the deeper layers of the cortex very large glia cells were found which normally Elsewhere the cortex appear only in the outer layers.
contained glia
cells

with slightly stained

cell

bodies

and

large pale nuclei with small vesicles, which were in close approximation to the degenerated nerve cells, not only at

body, like the satellite cells, but also surrounding it. This pathological lesion and the type of glia cells are not peculiar to catatonia, but they are found to
the base of the
cell

a striking degree in the deeper cortical layers in this disease. The onset of the psychosis is usually Symptomatology.
subacute, with a condition of mental depression quite The similar to that observed in the hebephrenic form. patients for several weeks before the onset may have ap-

peared unusually quiet, serious, or even anxious, complaining of difficulty of thought, of headache, or of peculiar sensations in the head. Besides this, they may have suffered

from insomnia and

loss of appetite,

and have

left their

work

because of nervousness and general ill health. Gradually the patients show great anxiety, and express fear of impendTheir religious emotions become more promiand hallucinations and delusions appear. A voice nent, from heaven directs them to do all sorts of things. One patient is commanded to spit to the right, and another to convert sinners. There is a vision of Christ on the cross, the Virgin Mary appears, faces are seen at the window and pictures on the wall, spirits hover about, some one speaks from the radiator, and there is music in the next room. They
ing danger.

DEMENTIA PILECOX

243

hear their children cry for help. Some one calls their name, and they hear their own thoughts. Little birds speak to

Specks of poison are detected in the food; sulphur fumes are set free about them; some one pulls at their hair,

them.

injects

The

water into their limbs, or applies electricity to them. delusions are usually of a religious nature, are inco-

herent and changeable from day to day. The patient is persecuted for his sins, a priest has come to anoint him before he dies.
is

God has

transferred

him

to heaven, where he

surrounded by angels. He no longer needs food, as Christ has forbidden him to eat. He is. eternally lost,
is

possessed of the devil, has caused destruction of the whole world; all are dead; he is surrounded by spirits, his children
are lost, the wife false, his body has been transformed into mules' hoofs, his hands into claws, his brain has been drawn

and while hung to a cross, his limbs and body have run away like molten metal. The delusions may later become expansive, though they are occasionally expansive from the The patient then believes himself transformed into onset.
off,

Christ, has all power,

can create worlds, has lived for thousands of years, possesses all knowledge, can cast out evil spirits, is a millionaire, owns railroads, etc.

During the
of

earlier stages of the disease

some

peculiarities

movement and

which may patients assume constrained attitudes, holding the arms in awkward positions, as in the form of a cross, etc., standing or walking in an awkward manner, all of which may
be symbolical of their ideas. One patient stood for hours with hands behind him and head thrown back, staring
fixedly at the ceiling,

action appear, particularly constraint, increase to a state of muscular tension. The

and another lay in the form of a cross upon the floor. In some there is a tendency to execute rhythmical movements, such as rolling the head from side

244

FORMS OF MENTAL DISEASE

to side, or expectorating at stated intervals in a fixed direction.

In this period of depression the consciousness
clouded, orientation
is

is

somewhat

slightly disturbed,

do not apprehend
fail

clearly

may know that they are at

and the patients what goes on about them. They home or in an institution, but they

to appreciate the mental condition of their fellowpatients, mistake those about them for friends and acquaintances, or they claim that everything is changed and that they cannot understand the mystery of it all. Some believe

themselves translated to heaven, that they are in a or in a foreign city.

cloister,

Thought
is difficult.

is

loose and somewhat desultory and reasoning The memory for remote events is well retained
is Although the surprisingly good. be mistaken for Christ or some one else, he

and
is

impressibility

physician

may

always remembered.
are seen.

Occasionally genuine falsifications of

memory The emotional
delusions
jected,

attitude is at first quite in

accord with the

and

hallucinations.

The

patients are sad, dedistrustful,

anxious,

complaining,

irritable,

and

sometimes threatening; when interfered with, they are very apt to become violent. Occasionally sexual excitement leads to masturbation and obscenity. Later they lose their
early anxiety,

become indifferent or contented with their and the delusions are expressed without environment, emotion. Some patients are even cheerful and happy, or
ecstatic.

The disturbances in conduct and actions are very striking. The patients cease work and lie listlessly about; they laugh
without apparent reason, indulge in excesses, neglect themselves, and sometimes utter threats. Many patients pray
constantly

and devote much time

to attending church ser-

DEMENTIA PR.ECOX
vices; not

245

a few attempt suicide or assault friends or relawithout reason. tives
Following this preliminary period of the disease, which most respects is quite similar to that in the hebephrenic

in

form, the more characteristic catatonic symptoms appear; namely, the catatonic stupor and the catatonic excitement.

In at least one-third of the cases these symptoms appear at
the very onset of the disease.

The catatonic stupor is chiefly controlled by the symptoms negativism and automatism. Negativism often occurs first in the form of mutism, when the patients refuse
to speak. They begin by speaking low, breaking off in the midst of a sentence or answering in monosyllables, then

whisper unintelligibly, and finally refuse to speak Some patients in this condition may be peraltogether.
they

may

suaded to write or sing answers to questions. When addressed they remain with closed eyes or staring fixedly at some distant object, apparently paying absolutely no attention to the physician. Even shaking patients, pinching them, or prodding them with a needle fails to elicit a re-

sponse, except

when

in pain;

then the

more

closely pressed together or the
indifferently.
is

may become patients may move
lips

away
and

Further evidence of negativism
persistent resistance

seen in the obstinate

which the patients make to every attempt at handling them. They resist being put to bed and being taken out, dressing or undressing, moving forward or backward, opening the eyes or closing them. The active resistance is well demonstrated by suddenly withdrawing the hand which has been placed against the patient's forehead, when it springs forward with a jerk. The physical origin of this resistance becomes more apparent in those cases in which the desired action is only elicited by com-

246

FORMS OF MENTAL DISEASE

manding the patient contrariwise. One may get a patient to open his eyes by urging him to close them tightly, to lower the hand by telling him to lift it, etc. Even the most natural impulses are resisted, as seen in their stubborn refusal to wear shoes or stockings, in the tendency to sit on the floor rather than in a chair, or to sleep under the bed and not in it, and go to the closet by the longest route. They prefer to eat another's food, and some
persist in crawling into the beds of others.

Finally the re-

fusal of food

and the retention of urine and feces are evidences
for a

of

months.

more extreme negativism. The absence of food

The former may last for week will not overcome
It is not

this disinclination to take food voluntarily.

un-

usual for this form of negativism, as well as the others, to appear and disappear suddenly. Sometimes the patients
will begin to eat

main

in

bed

if

transferred to another ward, or will regiven a different bed. The urine and feces
if

may

be retained until there
it is

is

marked

distention.

In a

few cases
There

necessary to overcome this by catheterization

and enemata.
usually associated with negativism an unusual uniformity of the muscular tension which is exhibited in several ways, especially in the extraordinary uniformity
is

by the body or its various parts. In this condition patients maintain the same position for weeks and even months. The usual position is on the back, with
rolled

of position maintained

limbs stretched out, the eyelids closed with the eyeballs upward and inward, or with the eyes open staring fixedly in the distance, the face mask-like with lips slightly
closed

same time protruded. The hands are very often clenched, as if there were permanent contractures, the fingers producing pressure marks on the palms. Plates 1 and 2 represent two stuporous catatonic patients. The
at the

and

PLATE

1.

Muscular tension

iu catatonic stupor.

DEMENTIA PILECOX
boy
rigidly

247

maintained this uncomfortable position for with his head thrown far backward, eyes tightly weeks, While in closed, and face mask-like with protruded lips. this condition he required daily feeding by nasal tube. The

maintained this same position for over four years without a known voluntary attempt to change it. The body and head are slightly bent forward with the eyes staring
directly in front of her, the lips protruded, the arms flexed, and hands so tightly clenched that cotton must be placed in the fists to prevent pressure sores.

woman

While in bed she

lies

straight upon the back with knees strongly adducted and arms drawn closely to the chest, but with the fists in the same constrained position. During this long period it has

been necessary to feed her by spoon. Others lie rolled up like a ball, with head thrown forward and knees drawn to the chin. In the extreme condition these patients may
be rolled about or
lifted

and

laid across

some

object without
is

movement, as

rigid as a piece of wood.

Muscular tension

not evenly distributed, but is most frequently seen in the hands, arms, face, and lower limbs. The gait is often influenced

by
all,

this condition,

some patients being unable to

move

at

falling rigidly to the floor

when

raised to their

feet; others walk

stiffly, with unbent knees, on tiptoes, or on the outer side of the feet with the body bent forward or

backward. The movements are usually slow and constrained.

Sometimes the counter impulses seem to be suddenly overcome and the movements become rapid.

The
less

hypersuggestibility

is

frequently in echopraxia

seen especially in catalepsy, and and echolalia, the latter of

which are usually
ical

of short duration.

In the echolalia and

echopraxia the patients simply repeat in a wholly mechan-

hear or see done in their presence.

and monotonous manner what they may happen to They imitate or mimic

248

FORMS OF MENTAL DISEASE

every act of some person in their environment. Questions asked are only repeated. The condition of catalepsy is She had well seen in the patient depicted on Plate 3.

been placed in this awkward and very uncomfortable posiThe feet are tion, which she maintained until relieved.
separated,

drawn backward, and elevated so that the toes barely touch the floor; the arms are elevated and drawn backward and the head is extended as far as possible. These disturbances of the will become evident when one
;

requests the patient to protrude his tongue, in order that it may be punctured with a needle. Although he sees the

needle and comprehends that you are threatening him with it, yet upon request he shoots out his tongue without hesitation,

and

will

command
These

him.

He

repeat the experiment as often as you frowns when pricked, but is unable to

suppress the impulse released by the

apparently opposite states of negativism

command. and hyper-

suggestibility

may

stage to loud and unrestrained shouting or to incessant gives way prattle; the patients awake from the stupor and talk as if

during

the

of

pass directly from one into another stupor. Absolute silence suddenly

nothing had happened, and again in a few hours relapse into their former stuporous state. Sometimes these changes

can be brought about by mere suggestion. are quite characteristic of catatonia. Interrupting the stupor or following it,
even preceding
is
it,

Such changes

and sometimes

we have

the catatonic excitement, which

characterized

ments.

often follows the initial condition of depresrapidly sion already described. The patients suddenly leap from bed, tear their clothing, break the furniture, race about the

The and

by impulsive actions and stereotyped movecondition of excitement usually develops

room, shouting or singing, throw themselves upon the

floor,

PLATE

2.

Muscular tension

in catatonic stupor.

DEMENTIA PR.-ECOX

249

rotating the head from side to side, breathing rapidly, churning saliva in the mouth, or making a peculiar blowing

sound.

They may run about the house

for hours at

a time,

While lying striking the bed or the wall in a certain place. in bed the body may be swayed regularly back and forth,
or the bed tapped at a certain place at regular intervals In walking they are apt to assume peculiar attitudes.

One
a

patient stood for hours against the wall in the form of " the Father, the Son, and the Holy cross, repeating,
77

; another, holding his nose tightly with his hands, uttered a monotonous grunt for hours at a time. Mingled with these movements are seen numerous impulsive move-

Ghost

ments when the patients jump about from one object to another, pounding themselves, knocking their heads against the wall, wringing their hands, jumping up and down on the bed, and stamping on the floor. All of these most varied movements are carried out with great strength and recklessness,

and are

without regard for the surroundings or themselves, for the most part purposeless and impulsive. In the

midst of their ceaseless tramping about the room they may suddenly grab at the clothing of the physician or assault a fellow-patient. During this excitement the patients are
very untidy and filthy, expectorating in the food, smearing with feces and food, urinating in the bed and clothing, and evein washing themselves with urine. Sexual excite-

ment veiy often accompanies this condition. Mannerisms in facial expression and speech are especially characteristic of these catatonic states. Accompanying
speech there
is

senseless shaking

a peculiar gesticulation, winking of the eyes, and nodding of the head, and drawing of

the muscles of expression. intonation or may quiver.
scanning, rhythmical, or

The voice assumes a peculiar The manner of speech may be The content of speech explosive.

250
is

FORMS OF MENTAL DISEASE

less syllables

often quite characteristic, consisting of a series of senserepeated in a fixed measure or rhyme. Words

or short sentences are likewise repeated; the words may be clipped or the last syllable drawn out. Usually these
expressions bear no relation to the trend of conversation.

One

patient,

when asked how he
I see

felt,

repeated for three
the

minutes,

"I see you, Another common

you."
is

disturbance

inconsequential

The patients react to every answering of questions. but not according to its sense. The answers question
are
generally
less

more or

irrelevant, though occasionally they have remote reference to the question as though

the desired information was avoided.

The

following

is

an

example: How do you

feel this

Did you
lady

sleep well?

"

It is a fine morning." morning? It was a cold night." Who is this

"

(indicating a nurse) ? " clothes (dressed in white).
(the

"

What

The lady with the black " is her name? Clara

Swanson"

name

of

a

fellow-patient).

How many

windows are there

in the

many of us are
day
of the

there in
is

room? "Three" (four). How " " the room ? Three (four). What
"September 35" (October
5).

month

it?

How much money have I here? " Two dimes " (a quarter). How much now? "Two dollar bills" (one dollar bill),
etc.

Such responses

in a medico-legal case

would be very sug-

gestive of simulation, but their apparently close relationship to negativistic states should in such cases lead one to

search for other negativistic signs.

In their voluntary speech genuine desultoriness is often seen (see example, p. 40). Neologisms, the repetition of senseless expressions, and the use of sentences that are wholly
devoid of connection are frequent, while at the same time

PLATE

3.

Cerea

flexibilitas in catatonic stupor.

1.

Catatonic writing showing verbigeration.

DEMENTIA PR^COX

251

voice.

the patient affects lisping and grunting, or speaks in a falsetto Agrammatism is sometimes present, in that the

patients

seem unable to construct sentences and use only

infinitives in speaking.

Verbigeration is also a frequent symptom in the catatonic excitement as well as in the stupor. It consists in the use of many motor expressions, the tendency to stereotypy,

and the

repetition of similar impulses.

The

patients will

repeat for hours
sions, or single

and even days at a time senseless expressyllables, usually in the same monotonous

manner, though sometimes modified by shrieking or singing them. Verbigeration is especially noticeable in the
voluntary writings of the patient, which are
striking

made

still

more
of

by

excessive underlining, shading,

and addition

symbols. Catatonic stupor often passes abruptly into catatonic excitement and vice versa. The excitement is more apt to
precede.

Sometimes one state replaces the other

for only

a few minutes or hours.

The degree

of stupor or excitement

varies considerably in individual cases.

During the stage of catatonic stupor and excitement, the is somewhat clouded, but the patients seldom lose their orientation completely. In spite of the fact that seem quite unconscious of and unable to comprehend they
consciousness

awake from a condition and give the names of those about them, telling the day and the month, and showing surprising knowledge of what has happened within their limited range of obsertheir surroundings, the patients will

of stupor

vation.
Partial insight into the conditions of stupor

and

excite-

ment

is

frequently expressed

by the

patients,

when they

refer to their peculiar acts as foolish,

but say they could not
felt

help doing them.

Others say that they

compelled to

252

FORMS OF MENTAL DISEASE

until

do what was requested, that they could not remain quiet it was done, or that they are commanded by God but whatever the explanation, it is apparent that their peculiar
;

acts are distinctly impulsive
ing.

and not the outcome

of reason-

The

states exhibits

emotional attitude during these distinctly catatonic no striking disorder. They are mostly in-

different as to their delusions and conduct. Threats make no impression upon them. Provided negativistic symptoms are not present, they will not wince when threatened with a burning match or an open knife, and will not even

wink when the eye

is

approached with a needle.

Occasion-

ally there are observed changeable states of childish petulancy, irritability, or silly elation and ecstasy.

In some cases elevated temperature, varying between one hundred and one hundred and two degrees during the acute onset of the symptoms, may persist
Physical Symptoms.
for

ized

Cyanosis, dermography, and localoften occur. Convulsive attacks are also sweating encountered in a few cases, mostly at the onset. There

two or more weeks.

is

during the stage of depression. This becomes more prominent during the stupor and may reach
loss

of weight

extreme emaciation in

spite

of

forced

feeding.

Later,

sometimes

stupor, the weight rises. the stage of deterioration the patients usually beDuring come quite fleshy. During stupor the skin is cold and clammy, the heart's action slow and feeble, and the bowels

beginning

during

constipated. Course.

The usual course

in the catatonic

form

is

de-

pression and stupor, followed by excitement, passing into dementia. In a few cases the stupor is immediately fol-

lowed by dementia without the intervention of the characteristic

excitement.

Occasionally the excitement precedes

DEMENTIA PILECOX
the stupor and
disease.

253

may even appear

at the very onset of the

prominent feature in the course of the disease, which rarely appears in other forms of dementia prsecox, is the Remissions for a few days or a few hours occur remissions.
in almost all of the cases.

A

The consciousness

of the patients

becomes perfectly clear. They apprehend and remember events, are quiet and rational, and often express a feeling
of illness.

At

these times close observation discloses a

manner and actions, an inconsistent and a lack of full appreciation of their emotional attitude, previous condition. These brief remissions occur most frequently in the states of excitement and are both less frequent and less complete in stupor. In at least twenty
certain constraint in

per cent, of all the cases, the remissions are long enough for the patients to seem to have completely recovered. Yet, in these cases, one often detects peculiarities which indicate
that recovery
ness,

and

not complete, such as irritability, seclusiveA reforced, affected, or constrained manners.
is

lapse usually occurs within the

first five

years,

though

it

may

not come within fifteen years.
in fifty-nine per cent, of the cases is ulti-

The outcome

In these cases, mately pronounced mental deterioration. the stupor and excitement disappear and the hallucinations

and delusions become less prominent, but the patients give numerous evidences of dementia. They are stupid and indifferent, and have lost their mental activity. They are
able to comprehend simple questions, but they lack mental The memory is defective, the judgment poor, and initiative. they are unable to acquire new knowledge. They have no

regard for themselves, their personal appearance, or their future. They remain contented wherever they happen to
be,

and never express any

desires.

They

are wholly unfit

254
for intellectual

FORMS OF MENTAL DISEASE

employment, as they have no idea of how to work. Upon questioning, and in a few cases voluntarily, delusions and hallucinations are expressed; the former are usually expansive but quite incoherent, and without effect

upon the conduct

of the patient.

Some
selves,

in one place

of the patients are very inactive, remaining stupidly most of the time, sometimes muttering to them-

but taking no interest in their surroundings. Other patients are active, restless, and unbalanced. In both of
these groups, and especially in the latter, we find mannerisms. The movements lack freedom, are constrained and peculiar;

the patients walk on tiptoe, along cracks, or with bent limbs, with head thrown forward and with cramped hands. The

head

is

usually held in peculiar positions.

When

sitting,

they always assume fixed positions, shaking or nodding the head at regular intervals, making a blowing noise with the
to meals only through certain doors, or perhaps backwards. The mannerisms are especially marked in dressing and at table. They may eat
lips or grunting.

They pass

with great rapidity,

filling

the

mouth

to

its fullest

extent

before swallowing. Others eat very deliberately, waiting a certain interval between mouthfuls, perhaps counting three, each bit of food being prepared and carried to the

mouth

in a certain definite

manner.

Many

patients eat

with their hands, others hold the knife and fork in some
peculiar fashion.

One

of

my

patients refused to eat unless

he had been allowed to stand on his head and crawl under
the table.
writing.

Similar mannerisms are evident in speech

and

In speech, neologisms may prevail, especially the transitory periods of excitement, when in addiduring tion there may be a genuine word- jumble.
deterioration gradually deepens, particularly following the short periods of excitement, which appear in most

The

DEMENTIA PR^ECOX

255

At these times the patients are restless, irritable, cases. and threatening, and express delusions of persecution. The speech, in addition to shouting and laughing, shows marked
confusion.

Impulsiveness also

the

destructiveness,

prominent, as seen in aggressiveness, and even homicidal
is

attempts.

In twenty-seven per cent, of the cases the dementia is of a Here the patients return to clear consciouslighter grade.
ness, are quiet

home, and in a few cases resume their former occupations. But a profound change in character has occurred; their former mental

and

orderly, able to return

vigor does not return, they are

listless, dull, and lack energy and endurance. Their judgment is defective. They are cleanly and orderly in conduct except for a few catatonic

mannerisms.
distrustful,

Some
or
silly.

of the patients are very quiet, seclusive,

self-conscious;

while others are somewhat

childish

and

These cases not infrequently present periodical attacks

of

excitement very similar to those exhibited in manic-depressive These attacks are of short duration, not more insanity.

than a few days or weeks, but the intervals vary greatly.

The

patients become loquacious, distractible, less accessible, are elated, and have a pressure of activity in which the movements are mostly purposeless, stereotyped, and characterized

These periodical attacks may not develop until after several years have elapsed. There should also be included here a series of cases in which there is a

by impulsiveness.

regular alternation between brief periods of excitement and brief intervals. In women these attacks seem to bear some
relation to the

menses (menstrual insanity). The patients begin to laugh much, to wink their eyes, and to wander about; then there suddenly develops an extremely active

excitement.

The weight

falls

rapidly,

sometimes

five

to

256

FORMS OF MENTAL DISEASE

eight pounds in twenty-four hours. The improvement comes almost as rapidly, although toward the end of the attack

a slight diminution of the dazedness and activity. The patients become clear and orderly, but for a time conthere
is

tinue very quiet, apathetic, and rather stupid, and usually fail to gam an insight into their condition, although they may be able to recall several incidents of their psychosis.
is regained rapidly. These attacks may recur at intervals of one to three weeks for a long time. In the greater number of these cases the intervals become shorter,

The weight

but in either event there ultimately develops a condition of
profound dementia. About thirteen per
cent, of the cases

seem

to recover.

Some

of these patients manifest slight peculiarities in conduct

and a change

which is apparent only to those A number of these cases closely associated with them. later in life suffer from another attack, terminating in
in character

dementia.
Unfortunately,
will recover,
it

what

impossible to determine what cases cases will have long remissions or will
is

become

deteriorated.

This

much can be

said,

however,

that those with an acute development, also those in which the stupor or excitement is very pronounced, are more apt
to have a remission.

Marked improvement is not a favorable

indication, provided that with the clearing of consciousness, there is not a corresponding improvement in the emotional

attitude;

if

senseless delusions are expressed without corif

responding effect or excitement;

mannerisms and stereo-

typy persist; and

a recurrence of periods of excitement. Prolonged stupor of itself does not necesindicate deterioration, as patients have remained in sarily
finally, if

there

is

stupor from three to five years. The fatal termination of the catatonic cases usually occurs

DEMENTIA PILECOX
as the result of
culosis is

257

some intercurrent

disease, of

which tuber-

the most prominent.

PARANOID FORMS
In both the hebephrenic and catatonic forms of dementia prsecox delusions are characteristic, but they tend In the paranoid forms of the to fade within a short time.
disease,

on the other hand, delusions and usually

also hal-

lucinations persist for
of

many

years, although there are evidences

a more or
clear.

less

rapid deterioration while consciousness re-

mains

The paranoid forms, comprising twenty-two
group of dementia prsecox, consist of

per cent, of the entire

two groups of cases. First Group (dementia This group is paranoides). characterized by the persistence of numerous incoherent and changeable delusions of both a persecutory and an expansive nature associated with a moderate degree of excitement, and a rather rapidly developing dementia. The onset of the disease, as in the Symptomatology. other forms, follows a period of headache, malaise, and insomnia with a rapid loss of energy and often irritability. The patients act peculiarly, are unusually devout, seem depressed and anxious, and remain alone. Very soon they
divulge a host of delusions, almost entirely of persecution; people are watching them, intriguing against them, they are not wanted at home, former friends are talking about

them and trying to injure their reputation. These delusions are changeable and soon become fantastic. The patients claim that some extreme punishment has been inflicted upon
them, they have been shot down into the earth, have been transformed into spirits, and must undergo all sorts of torture.

are being replaced a

Their intestines have been removed by enemies and little at a time; their own heads have

258

FORMS OF MENTAL DISEASE

been removed, their throats occluded, and the blood no longer circulates. They are transformed into stones, their countenances are completely altered, they cannot talk, eat, or walk like other men, etc.
Hallucinations, especially of hearing, are very prominent during this stage; fellow-men jeer at them, call them bastards, threaten

them, accuse them of horrible crimes, and

numerous slanderous telephone messages are overheard. Occasionally faces and forms are seen at night, or a crowd of men throwing stones at the window. Foul vapors may be thrown into their bedding. The patients show agitation; they are anxious, restless, quarrelsome, and emotional. They laugh, cry, and sing.

The

orientation
all

perform

In conduct, they may is not disturbed. kinds of serious and outlandish acts, attempting

and committing arson. The emotional attitude soon changes and becomes more and more exalted. At the same time the delusions become The less depressive and more expansive and fantastic. patient in spite of persecution is happy and contented, extravagant and talkative, and boasts that he has been transsuicide, assaulting persons,

formed into the Christ; others
lived

will

ascend to heaven, have

many lives, and traversed the universe. They have the talent of poets, have been nominated for President, and have represented the government at foreign courts. These delusions may become most florid, foolish, and ridicuA patient may say that he is a star, that all light and lous. darkness emanate from him; that he is the greatest inventor ever born, can create mountains, is endowed with
all

the attributes of God, can prophesy for coming ages, can talk to the people in Mars; indeed, is unlike anything that

has ever existed.
Associated with these variegated and ever changing ex-

DEMENTIA PILECOX

259

pansive delusions there are delusions of persecution almost as absurd and extreme, but expressed without corresponding emotion. Patients smilingly complain that they have

been deprived of their limbs, have been pierced with thousands of bullets, and been thrown into hell, where they were
exposed to furnace flames. Suggestions for many of these delusions may be obtained from pictures on the wall or from
reading.

The

hallucinations also

become more extreme.
daily,

Angels descend from heaven and

commune with them

God

them, the President directs their conduct, beautiful visions are displayed at night which are full of
also talks to

meaning. These patients are usually talkative and express freely Some of them fill hundreds of sheets their many delusions.
of paper trying to describe them.

At

first

they are quite

coherent, but later there is such a wealth of ideas loosely expressed that it is difficult to follow them. They wander aimlessly about from one delusion to another,

and show same ideas. Questions, however, are answered in a coherent and relevant manner. Later in the course of the disease the speech becomes more and more difficult of comprehension, because of the number of peculiar phrases and neologisms to which they attach The writings likespecial significance and freely repeat. wise become more and more unintelligible. The patients rarely possess insight into their condition. The consciousness usually becomes somewhat clouded, esfrequent repetitions of the
pecially later in the disease.

Orientation as to place is least disturbed, but people are soon mistaken and often designated as celebrated personages, and all conception of

time is lost.

Patients recognize relatives and can give a fairly

where they are. They may recall some past knowledge, but they soon become unable to use
clear statement as to

260
it

FORMS OF MENTAL DISEASE
to follow long conversations. cannot apply themselves to any mental work. The
fail

in reasoning

and utterly

They

patients
feelings,

show an

exaltation of the ego with heightened

and demand
patients

they are self-conscious, with an important manner, In emotional attitude they special attention.

are almost always exalted, rarely depressed, although a few
irritability, and occasionally often in connection with the menses. Insome passion, creased sexual excitement is also common. Some patients are able to do some mechanical work, but need supervision

show restlessness, some

because of their capriciousness and fickleness.

There is very little physical disPhysical Symptoms. turbance except the loss of weight and insomnia at the onset, faulty nutrition,

and

occasionally increased vasomotor

irritability

Course.

with easy blushing and blanching. The course is progressive without remissions.

The

signs of mental deterioration

may appear

within a few

months, and are usually well marked by the end of two years. The patients may for a long time retain clear consciousness and partial orientation, but the content of thought becomes thoroughly incoherent and there is a lack of energy and plan in their activity, which incapacitates them for all mental application. While active and somewhat interested
display a self-conscious From this stage of dementia there may be no serenity. further progress for a number of years. Occasionally transitory exacerbations of excitement or depression occur.
in
their

environment, they

still

Finally there may be periods when the patients disclaim their delusions and refer to them as foolishness, but at the

same time they do not regain
Second Group.

clear insight.

is provisionally grouped here a which are characterized by fantastic delusions usually accompanied by numerous hallucinations

There

larger series of cases

DEMENTIA PR^ECOX

261

which are more coherently developed and expressed for a number of years, when they either become incomprehensible or dis-

appear

altogether, leaving the patients in

a condition

of

mod-

erate dementia.

Symptomatology.

The

first

symptoms

those of despondency with some

to appear are self-accusation. The pa-

tients are troubled with thoughts of

death and religious

vice.

doubts; they are unusually devout, and seek religious adThey fear that they have done wrong, have committed

some

crime, or are suffering the penalty of self-abuse. Coherent delusions of persecution develop gradually; people watch them, peculiar actions are noticed, acquaintances

are less friendly, and children on the street jeer and laugh at them, perhaps mimicking their manners. Strangers on the street turn and stare. In public places, in the cars, and
at the church, they observe peculiar acts which refer to them. They believe themselves libelled by the newspapers. They

understand these mysterious occurrences and

will shortly

Affairs at expose the offenders and bring them to justice. home are unsatisfactory; the children are different, and the

husband or wife

is

unfaithful.

Hallucinations) especially of hearing, rarely of sight, are prominent at this time, aiding in the elaboration of the

Enemies take advantage of their confinement by standing below the window, calling them all sorts of names,
delusions.

announcing that they are to be imprisoned, that they have committed murder, and are to be put to the rack. Voices
are heard from the walls

and from under the floor, stating that they are wretches and outcasts of society. Very often the noises really heard, such as the blowing of whistles and
the ringing of
delusions.
bells,

They

are misinterpreted in accord with their complain that the food contains poison

which they can

taste,

they suspect phosphorus in the tea

262

FORMS OF MENTAL DISEASE
clothing.

and detect kerosene on the

They

notice that

their clothing is changed, buttons are missing, there is a rip in the coat and a pocket torn. Objects in their surround-

ings are changed in order to confuse them.

Delusions of physical influence become particularly prominent. Many common somatic sensations, such as twitching of individual muscles, headache, specks before the eyes,

pain about the heart, and cramp in the bowels are all evidences of such influences wielded by their enemies. The
explanations of these somatic sensations are often most An itching of the foot is sufficient evidence fantastic.
that a poisonous powder has been blown into their shoes, pain in the back indicates that they have been shot there
while asleep, a frontal headache is the result of poisonous vapors, which are set free in the room at night in order to A tremor of the fingers is prodestroy their intellect.

duced by means of electric currents sent through the air. Something is placed in their food to create sexual
excitement.

Their persecutors employ the most varied means in pro-

ducing physical discomfort.

All

known

agencies are men-

tioned, as, magnetism, hypnotism, X-rays, telepathy, and electricity. Organs of the body are removed and then re-

placed out of order, and the intestines are shrunken. It is quite characteristic for the patients to refer to these physical changes by some invented names, such as, ugly duberty,

Others complain that their minds are influenced, their thoughts are gone, they have no control over their thoughts, which, in spite of themselves,
snicking, lobster cracking, etc.

are always to others.

evil.

attribute the origin of such thoughts " Frequently they complain of drawing of the

They

thoughts," and they may say that they don't know whether their thoughts are their own or suggested by some one else.

DEMENTIA PILECOX
Sometimes
especially their thoughts

263

become audible (double thought),
Their thoughts are

when

reading.

known

to the

whole world.
Ideas of spirit-possession are often a prominent feature. Here the enemy enters and takes possession of the body,
causing the bones to crack and the head to rattle; obscene remarks proceed from the stomach; their ears are filled by
all

sorts of noises

made by
fall

cause the testicles to

and

these spirit-possessors. the throat to dry up.

They

In connection with the delusions of influence there develops in almost
sive delusions.
all cases more and more pronounced expanThese are as variegated and fantastic as persecution. The patients have been awarded a

those of

prize for bravery
dresses,

and now

rule the country, possess beautiful

and are betrothed to the king, etc. God daily appears to them and gives them a blessing. They have
recently been intrusted with millions which they are to invest in mining. They have consummated an immense

which they are president. All of the many delusions expressed by the patients are at first coherent, and may be partially systematized; but in the course of a few years, they tend to become somewhat incoherent, and at the same time
trust, of

the hallucinations become more agreeable. The consciousness during the development of these delusions,

and
clear,

for a long time afterward, perhaps years, re-

mains
able at

and the patients are
to offer to

oriented.

Thought

is

coherent, but centers about the delusions.
first

The patients

are

objections,

ideas; as deterioration appears gradually in the course of several years, thought becomes confused, and the delusions

and

some basis for the delusions, to show some " method " in their

refute

but

later,

incoherent, contradictory, and changeable. There is rarely insight into the disease. Many patients appreciate that they

264

FORMS OF MENTAL DISEASE
and ailments are rather

are not normal, but their defects

regarded as the work of their persecutors. The emotional attitude is at first one of depression, with anxiety and combativeness, but later this gives way to a
certain

amount

of happiness

and

cheerfulness, with con-

There may be transitory outbreaks of siderable egoism. In some cases stuporous anxiety as well as of irritability.
states

have been observed.
conduct
is

The

mostly in accord with the delusions; the

patients are suspicious, journeying about to get rid of their enemies, applying to police for protection; or, taking the

matter in their
or attempt to

own hands, they attack supposed persecutors Others for expose them through the papers.
armor
for themselves, place

self-protection contrive a sort of

metals in their shoes or wires in their clothing to divert the In accord with expansive delusions electrical currents, etc.

they may decorate themselves in fantastic costumes, adorn themselves with badges, assume a superior air, and use highflown language.

Furthermore, during the course of the disease peculiarities of conduct develop, such as, grimacing, striking gesticulations,

mannerisms in

eating, walking,

and speaking, as

well as signs of negativism or of stereotypy. Course. The duration of the disease extends through many years. It is sometimes possible to discern certain

stages in its development: at first a change of disposition, then a prominence of delusions of persecution, later the appearance of delusions of grandeur, indicating the onset
of deterioration, of

collapse

may

occur.

away and entire the delusions. Remissions in the symptoms The outcome is always deterioration. The
and
finally the

fading

rapidity with which the dementia develops varies greatly. Usually some signs of dementia appear within two or three

DEMENTIA PILECOX
years.

265

other hand, there are cases which deteriorate within a few months, and there are others which do not

On the

fade, are never exare forgotten or wholly denied, and at the same pressed, time there appears some insight. But in all these cases

dement for a number of years. In some cases the delusions gradually

there

still

remains some impairment of

memory and

judg-

ment, apathy, and a
activity.

energy and Or the delusions and hallucinations may be reloss of the characteristic

tained, while the patients become quite indifferent to them, rarely complain of persecutions or show agitation. They are usually capable of employment, and sometimes

and

" " are even industrious, the former Pope becoming a trusted " " farm-hand, and the queen a good seamstress.

More frequently the outcome

is

characterized

by an

in-

creasing confusion of thought, when the delusions become more and more incoherent and unintelligible, while the
peculiarities of

conduct increase with a tendency to occaIf the detesional states of excitement and impulsiveness.

rioration advances further, the patients of silly, quiet dementia.

may

reach a stage

There are not only no pathognomic signs of dementia prsecox, but even some of the more characteristic signs of the disease, such as, negativism,
automatism, stereotypy, and mannerism, occur in other
eases; for instance, paresis, senile
dis-

Diagnosis of dementia praecox.

and other organic psychoses, as well as in some of the infection psychoses, and even hi manic-depressive and epileptic insanity. Hence the diagnosis must rest on the entire picture and not upon any single
symptom.
cesses
is

may

While it is possible that different disease proexhibit at times similar groups of symptoms, it

altogether improbable that these

same

diseases will at

all

times resemble each other, both as regards the manner

266
in

FORMS OF MENTAL DISEASE

which the symptoms develop, their course, and their outcome. The slowly developing cases of hebephrenia must be distinguished from acquired neurasthenia. This differentia-

tion depends especially
tia,

upon the presence

of signs of

demen-

the

silliness

of the hypochondriacal ideas,

especially

sexual hypochondria, faulty judgment, emotional apathy, and the fact that the patients do not improve with quiet and
relaxation.

The emotional apathy of the hebephrenic stands out in contrast to the increased emotional irritability of the neurastheniac. Finally, any evidences of hallucinaof

tions,

automatism,

or

stereotypy

distinctly

indicate

dementia praecox

(see also p. 155).

dementia praecox, occurring in middle life, from paresis in which the physical symptoms have not yet appeared, may be quite difficult. The catatonic
differentiation of

The

symptoms that

occasionally occur in paresis catalepsy, and stereotypy are by no means mutism, verbigeration, as varied and characteristic as in catatonia; while the general

incapacity and genuine weakness of will is more prominent in contrast to the eccentricities and the unruliness of the
catatonic.
is

Furthermore, the mental deterioration in paresis

apt to be more rapid and more profound and character-

by greater disorder of the apprehension, orientation, and impressibility of memory, while these faculties in comparison with the emotional stupidity and the weakness of judgment in dementia praecox are retained for a relatively long
ized
time, although they may be temporarily overpowered by negativism. The appearance of definite hallucinations and of
persistent

dementia praecox. The speech disturbances of the paretic may be closely simulated by the mannerisms of dementia prsecox; even epileptiform

mannerisms speaks

for

and apoplectiform attacks may occur

in dementia praecox.

DEMENTIA PR^COX

267

In such doubtful cases one must depend upon the lymphocytosis in the cerebrospinal fluid as determined by lumbar puncture

and the microscopic examination

of the

fluid

(see p. 103).

In the acutely developing cases of dementia praecox, the
clouding of consciousness and the confusion of speech often render it difficult to distinguish amentia. Here one must

depend upon the presence of negativism, stereotypy, and
present in amentia, they are not marked. In amentia, the patients are more natural in their The acts, less constrained, and not silly and eccentric. of memory is far more disorientation and impressibility

automatism.

If the latter are

turbed in amentia than in dementia praecox. The amentia patient, in spite of his best efforts, is unable to solve long

mental problems, loses the thread in long conversations, and indulges in incoherent reminiscences, yet he is able to answer

some questions rapidly and to the point.

On the other hand,

the dementia prsecox patient answers in a silly manner or perhaps not at all. Again at times he surprises one by
his correct conversation,

or he even solves
historical

and his thoughtful, bright remarks, a difficult problem and recalls correctly
facts.

and geographical
is

In amentia the emotional

attitude
altation

and

exceedingly changeable from depression to exvice versa, while in dementia praecox, even

during excitement, a certain emotional stolidity and apathy The amentia patient may not have a very accuprevails.
rate knowledge of the surroundings, yet he attends to and watches what takes place ; but in dementia praecox the patient exhibits remarkably little interest in those things

that he comprehends well.

Finally, in

amentia there

is

always a history of some exhausting etiological factor, which only occasionally antedates dementia prsecox.
Beginning cases of catatonia

may be mistaken

for epileptic

268

FORMS OF MENTAL DISEASE

befogged states, particularly when an epileptiform attack has occurred. The negativism of the catatonic contrasts with

the anxious resistance of the epileptic, while orientation is much more disturbed in the epileptic. Silly answers to

simple questions and rapid and correct obedience to commands speaks for catatonic. In epileptics an anxious or
ecstatic emotional attitude prevails.

more apt to make frequent assaults while the impulsive acts of the catatonic are purposeless and manneristic.

The epileptic is much and attempts at escape,

The

greatest difficulty arises in distinguishing the depresinsanity from the periods which one encounters at the onset of the hebe-

sive phases of manic-depressive

of depression

phrenic and the catatonic forms.
hallucinations

The

early appearance of

many delusions, especially ideas of physical influence, and the retention of a clear consciousness speak for dementia prsecox, as well as an emotional attitude which does not correspond to the depressive
senseless

and

character of the delusions.

The

catatonic patient remains

quite indifferent during the visit of a relative, while in manicdepressive depression the feelings are apt to be intensified. Hypersuggestibility of the will may exist in both conditions,

but a manic-depressive patient will not upon request protrude his tongue for the purpose of having it perforated with a needle. The uniform lamentations that sometimes occur
in manic-depressive

depression are the expressions of a
feeling of sadness,

persistent

and overwhelming

and not

the result of a senseless persevering impulse. The conditions of negativism of the catatonic and of anxious resist-

ance and retardation of the manic-depressive are at times distinguished only with difficulty. In the former there is
uniform, rigid, and stubborn resistance to every passive movement, and if pain is produced by pricking the eyelid,

DEMENTIA PR^COX
there
is

269

a simple withdrawal without effort at defence; while in retardation the passive movements are mostly permitted. In case the retarded patient shows some resistance

he does not persist in returning his hand to the same position, and if one threatens to approach him he utters an outcry,
shrinks back, or defends himself. Voluntary movements in catatonic stupor are rare, but when executed are carried

out without delay, and at times even rapidly, except when these movements are made by request, then there is always

In retardation, all voluntary movements are carried out very slowly. There is sometimes a certain resistance
delay.

due to apprehension and fear, but this is active. The differentiation between manic-stupor and catatonic
stupor
istic
is

quite difficult

and depends upon the characterdistractibility of the attention

happy temperament,

by the environment, the susceptibility to command, the accessibility to conversation, and finally the occasional
purposeful and frolicsome character of the movements of manic-stupor in contrast to the silliness, indifference, insusceptibility,

and the

senseless impulses of the catatonic

stupor.

The excitement
from

of the catatonic

is

to be distinguished
of manic-depressive

the excitement of the

manic phases

In the catatonic excitement the clouding of coninsanity. sciousness is less marked than in the manic excitement,
the patients being partially oriented, even in the greatest excitement, while in the extreme manic states there is the catatonic

complete disorientation. On the other hand, the speech of who has less motor excitement is more senseless
difficult to follow

and

than that of the manic who has ex-

treme motor excitement.

The

catatonic speech abounds in

verbigerations and stereotyped expressions and is free of comments upon the surroundings, while the speech of the manic

270

FORMS OF MENTAL DISEASE

presents the characteristic flight of ideas, and is centered upon, or drawn largely from, the immediate surroundings.

Also attention

readily distracted by the surroundings, while the attention of the catatonic cannot be. The emois

tional attitude of

the manic

is

exalted, frolicsome,
is

and

irritable, while that of the catatonic

silly,

childishly

happy, and

indifferent.

The movements

of the catatonic

are purposeless, frequently repeated, in contrast to the pressure of activity of the manic, in whom the movements are

always purposeful, related to the surroundings, dependent upon ideas, impressions, and emotions, and always appearing In catatonia there is no parallel between the in new forms.
excitement in speech and that in movement; for instance, the patient may be extremely productive, lying quietly in
bed, or he

may be

The increased
of the

extremely active and not utter a word. activity of the catatonic is more apt to be

room or of the bed, while that limited only by his confines, and in addition to this the individual movements of the catatonic tend to be
limited to one corner of the

manic

is

manneristic, stilted, unnatural, and associated with silly impulses; those of the manic, natural and more comprehensible.

The extreme

excitement of the paretic

may

resemble closely

the catatonic excitement.

In addition to the history of the

development of the disease, the age, and the physical signs, paresis may be recognized by the more profound clouding
of consciousness, the greater disorientation, of the impressibility of

and disorder

memory.
where there have been hysfrequently be differentiated from
latter fails to

Dementia
terical

prsecox, especially

attacks,

hysterical ness, the

must The insanity.

show the

desultori-

weakness of judgment, the indifferent emotional

attitude,

and the

similarity

and purposelessness

in the con-

DEMENTIA PILECOX

271

duct of the dementia prsecox patient. All of these symptoms stand in contrast to the shrewdness, capriciousness,
slyness,

and the purposeful obstinacy of the hysteric. Finally, pronounced hallucinations and delusions favor dementia prsecox. But there is still a large number of cases, which present at the outset clear symptoms of hysteria, but which later show unmistakable evidence of the deterioration of dementia prsecox. The very same condition may exist in manic-depressive insanity, in epilepsy, in paresis, and in brain tumor, which would favor
keenness, tyranny,

the view that in constitutionally defective individuals the early stages of these diseases may resemble very closely

the picture of hysteria. The distinction of the paranoid forms of dementia prsecox from pure paranoia depends upon the lack of system, the

rapid development of fantastic delusions commencing with prominent hallucinations; while in paranoia the onset is

very gradual, sometimes extending over one year with only a few hallucinations. The delusions in dementia prsecox
are extremely fantastic, changing beyond all reason, with an absence of system and a failure to harmonize them with

furthermore, the delusions of physvery prominent. In paranoia the delusions are largely confined to morbid interpretations of real events, are woven together into a coherent whole, gradually
life;

events of their past

ical influence are

becoming extended to include even events of recent date, while contradictions and objections are apprehended and In emotional attitude the dementia prsecox explained.
patients soon show clear and marked changes, depression or silly elation, sexual excitement, and remissions; while in paranoia the emotional attitude is uniformly natural,

the

demeanor
of

is

almost

capable

occupation

for

normal, and the patients are In paranoia a long time.

272
there
less

FORMS OF MENTAL DISEASE
be partial remissions when the patients react actively to the delusions, but the delusions never

may

disappear. In the absence of history of the early

life

and

of the psy-

chosis, imbecility may be confused with the end stages of dementia prsecox. The recognition of dementia praecox

then depends upon the presence of exacerbations in which dementia praecox signs appear and occasional utterances

which evince extensive
Treatment.

earlier

knowledge.
of the causes of

Our meagre knowledge

the disease restricts the indications for treatment to the
individual symptoms. The cases which develop acutely or subacutely demand careful watching in order to prevent
suicidal attempts. Unless this can be with the aid of a sufficient nursing force at accomplished home, it is best that the patient be sent to a hospital. Cases
self-injuries

and

form with gradual onset can be much more safely cared for at home. At the onset in all forms of the disease the patient must be placed in a quiet and restful environment, free from all irritating circumstances,
of the hebephrenic

and

in the charge,

if

possible, of a judicious nurse.

It is

usually advisable that the patient should not be in charge of a member of the family. In the acute and subacute
cases,

bed treatment should be regularly prescribed.

The insomnia is best combated by the simplest measures, as
hot baths upon retiring, warm liquid nourishment, or the hot or cold pack. If the patient does not secure six or seven hours sleep by the simple remedies, one may resort on alternate nights to sparing doses of some hypnotic, as, trional, veronal, somnos, chloral, or paraldehyde. These drugs

should not be given for long periods without being alternated. Conditions of excitement are always best controlled by the

prolonged warm bath (see p. 140), at

first

preceded by a pre-

DEMENTIA PILECOX

273

to -$ grain, or liminary dose of hyoscine hydrobromate in the same dosage. The extreme scopalamine hydrobromid

-^

excitement sometimes encountered, especially in the catatonic
form, may not yield to the prolonged warm bath, in which event one can often successfully employ hot or cold packs
(see
p. 321).

These

packs,

however,

are

not

applied

risk, and usually require the supervision of a physician. But in the employment of any sedative it must be borne in mind that the remedy is not curative, and, therefore, it is not advisable to employ high doses in order

without some

to wholly curb the excitement.

If it

seems essential to

secure quiet where these other measures have failed, one may occasionally resort to a hypodermic of hyoscine hydro-

bromate

-L^J-Q

ment
in a

is

still

with morphine sulphate J grain. If the exciteunabated, nothing remains but confinement

padded room with careful watching. Simple persuasion on the part of a well-trained, tactful nurse or physician often
succeeds in bringing about quiet, at least temporarily; but this requires great patience, a kindly disposition, and selfcontrol.

While the condition of nutrition demands careful attenit becomes parthe stuporous states. The patient ticularly urgent during should eat a liberal quantity of easily digested food. In

tion during the early stages of the disease,

order to estimate the state of nutrition such cases should

be regularly weighed at least once a week. During stupor with refusal of food, the patient should not be permitted
to go without food and water for more than three days. If the patient is illy nourished, one should resort to feeding by stomach or nasal tube at the end of thirty-six hours.

The patient may be fed artificially two or three times daily, the total amount aggregating two quarts of milk with six raw eggs, and, if need be, an ounce of olive oil, varying
T

274
quantities
of

FORMS OF MENTAL DISEASE
meat
juice,

and stimulants,

particularly

whiskey.

The excretory

functions

must be

daily watched, particu-

larly during the stuporous states, when patients retain the feces and urine. During the acute manifestations of the

frequent high flushings of the lower bowel with normal saline solution are well recommended.
disease,

During the periods of despondency at the onset of the disease, in addition to the bed treatment already referred
to,

the patient should be given an opportunity at times during each day to leave the bed for short periods and exercise.

Furthermore, simple methods of occupying the mind, at the same time affording some diversion, as, reading, playshould be a part of the daily routine. Friendly encouragement, with a frank discussion of the various delusions and hallucinations, persistently
ing games, needlework,
etc.,

carried out by a kindly and tactful nurse and physician, is not the least important feature of the treatment, and must not be overlooked.

As the more acute symptoms improve and the
increased activity subsides, the patient may to leave the bed for longer periods, but at the

fear

and

then be allowed

same time the

graduated exercise and mental application should be increased. The whole effort of the physician should then

be directed to developing remaining mental capacity and preventing further mental defect. This requires a considerable
in

amount

of specialized attention in the individual cases

order to prescribe means that at the same time are adapted to the patients' needs and traits and also are
suited to their environment.
sufficiently

Very many patients improve
able
to

so

that

they are
liberty.

return

to

their

homes or to their full must not overlook the

But

possibility of exacerbations,

in advising this, one and in

DEMENTIA PILECOX

275

women

the possibility of pregnancy, and the resumption of

excessively

burdensome home
of

cares.

advanced grades
surveillance.

deterioration

The cases exhibiting must be kept under
care of these

An

essential feature of the
is

mental shipwrecks
of doors.

healthful employment, preferably out

VI.

DEMENTIA PARALYTICA

(Paresis)

DEMENTIA PARALYTICA/
a chronic psychosis

or general paresis of the insane, is

of middle age, characterized by progressive mental deterioration with symptoms of excitation of the central nervous system, leading to absolute dementia and paralysis,

and

pathologically, by

a fairly

definite series of organic changes

in the brain and spinal cord, probably the result of some toxin, in the origin of which syphilis is most often an important
factor.

Etiology.
ilized

is most Europe and North America, hence, it seems to be a disease of modern civilization. In America, the disease comprises

The nations and

2

disease

is

unknown among the

unciv-

prevalent in western

from

per cent, of the admissions to insane institutions, but in some European cities, notably Berlin and Munich, the paretics average thirty-six to forty-five per
five to eight

The disease is somewhat more prevalent in large cities and manufacturing centers, while it is relatively rare in farming communities. The procent, of the

male admissions.

Voisin, TraitS de la paralysie gSneYale des alie'ne's, 1879 ; Mendel, Die Mickle, General Paralysis of the progressive Paralyse der Irren, 1880. Insane, 2. ed. 1886. v. Krafft-Ebing, Nothnagels spezielle Pathologic u. Therapie, Bd. IX, 2, 1894. Ilberg, Volkmanns klinische Vortrage, 161 ;

1

Binswanger, Deutsche Klinik, VI,
2

2, 59,

1901.

Diefendorf, Brit. Med. Jour., No. 2387, p. 744.

f.

Psy.,

XXVI,
3.

2.

Gudden, ebenda.

v.

Wollenberg, Archiv. Krafft-Ebing, Jahrb. f. Psy.,
.

XIII, 2 u.
Psy., 1900.

XIV,

321.

Oebecke, Allgem. Zeitschr. f Psy., XL. Hirschl, Jahrb. f. Bar, Die Paralyse in Stephansfeld, Diss., Strassburg,
276

DEMENTIA PARALYTICA

277

portion of male to female paretics is 1 to 3.9 to 7. This disproportion has recently gradually decreased. Negresses show

a striking tendency to the disease; in Connecticut, the negress paretics are ten times more prevalent than the female white paretics. Women suffer more often from the
depressive form and least often from the agitated form, and in them the disease lasts longer. Our average age of onset

hundred and seventy-two cases is forty-two years. Kraepelin in two hundred and forty-nine cases finds that it occurs preeminently in middle life, as eighty-one per cent, of the cases occur between thirty and fifty years, the disease
in one

rarely appearing
of age.

The

before twenty-five or after fifty-five years average age of onset in our women was two years

younger than in men, and one-third of the women became afflicted between thirty and thirty-five, while one-fourth of
the cases occurred after
finds that the onset in
fifty years.

women

Kraepelin, however, averages later. In our ex-

perience,

the onset

is

earlier in syphilitic

and

alcoholic

Our natives are slightly more prone to paresis than our foreign-born. l * Recently a number of cases of juvenile paresis have been reported occurring between the ages of ten to twenty years in which hereditary paresis, syphilis, and alcoholism are
prominent
acterized
Clinically, the juvenile form is chardeterioration of three to four years' duraby simple tion with numerous paralytic attacks, choreic disturbances,

women.

factors.

and paralyses. The disease afflicts
1

chiefly the unmarried,

and among the
De
la paralysie

Alzheimer, Allgem. Zeitschr.
v.

f.

Psy., LII, 3.

Thiry,

progressive dans le jeune age, 1898.

1901, 21.

Rad, Archiv
Frolich,

f.

Psy.,

XXX,

Hirschl, 82.

Wiener Klin. Wochenschr.,
Mingazzini, Monatsschr.
f.

Psy., Ill, 53.

Uber allgemeine progressive Paralyse der Irren

vor Abschluss der koerperlichen Entwicklung, Diss., 1901.

278

FORMS OF MENTAL DISEASE

women especially prostitutes; in our experience prostitutes are forty-five per cent, more prone to the disease than other women. Married women are usually childless. Not infrequently the disease occurs in man and wife; sometimes tabes is present in one and dementia paralytica in the other and paresis occasionally exists in the parents. The male
paretics come from all classes and from most professions and trades, though the disease is more prevalent among hotel and saloon keepers, quarrymen, carriage and hack drivers, bakers, sailors, hostlers, mechanics, masons, salesmen, and clerks, and least prevalent among farmers, servants, and

comparatively insignificant, except in juvenile paresis, as it occurs in only
factory employees.
is

Defective heredity

per cent, of cases. Among the causes of the disease, syphilis is statistically the most prominent. Its prevalence varies, according to
fifty

various authors, from one and six- tenths per cent, to ninetythree per cent., but most observers place it between thirty-

In our experience it existed in fifty-two per cent. Gudden in the Charite, and Kraepelin at Heidelberg cannot establish a clear history of syphilis in
four
sixty-five per cent.

and

more than thirty-four per

cent, of

male

paretics.

In other

but five and five-tenths per psychoses, we cent, of the cases. Therefore, there seems to be some relabetween syphilis and paresis, a view which receives tionship
find syphilis in

further support not only by the experiments cited by KrafftEbing, in which nine paretics inoculated with syphilis failed
to develop secondary syphilic lesions, but also

by the

clinical

observation that paretics infected with syphilis during the This latter is disease do not show secondary manifestations.

now doubted by Marchand, Gabiana, and Garbini, who have
reported seven cases in which paretics developed syphilis. Other apparently significant facts are the infrequency of

DEMENTIA PARALYTICA
paresis in
its

279

women

of the better classes

frequency

among
wife.

prostitutes,

and Catholic priests, and the occurrence of pare-

Other important causes are excessive which existed in sixty per cent, of our cases, head alcoholism, injury twenty-three per cent., and mental shock. Finally, a
sis in

man and

factor which cannot be overlooked
life

is

the ensemble of modern
insufficient relaxation,

with

its restless

overactivity and

coincident with the struggle for existence in large cities, and the common excesses in eating and drinking. In view of the uniform course of the disease Pathology.

leading to dementia and nervous paralysis, accompanied by a general and extensive destructive process, involving not

only the central nervous system, but also the general vascular system, and to a limited extent the internal organs of the

seems probable that we have to do with a toxic process. There exist symptoms of excitation of the neurones,
body,
it

their rapid destruction, gradual sclerosis, occasional exacer-

bations of the symptoms, and the possibility of a regeneration of the neurones, all of which can be reproduced by experimentation upon test animals with any toxic material

which causes a destruction
cal facts are

of the neurones.

These anatomi-

wholly in accord with the clinical observations ; the gradual onset, great clouding of consciousness, namely, rapid or gradual deterioration, and marked remissions, some

which almost approach complete recovery. The vascular and the broad extent of the process indicates that the toxin reaches the neurone by means of the blood vessels. The involvement of the kidneys, heart, and the entire vascular
of
lesions

system, the fragility of the bones, the alternate loss and increase of the body weight, ending at last in great emaciation, all speak for the profound general disturbance of
nutrition of which the mental are obviously the

most

severe,

but not the only symptoms.

280

FORMS OF MENTAL DISEASE
elevation of temperature, as well

The sudden and high

as the prolonged subnormal temperature,

and

finally the

paralytic attacks, judging from our experience in eclampsia, myxedema, and uremia, can best be explained by intoxicaViewed in tion arising from disturbance of metabolism.
this light, the

pathology of paresis resembles that of myxe-

dema, diabetes, osteomalacia, and acromegaly, except that in
these diseases the toxin does not involve the nervous tissue.

The character

of the toxin

and the sources from which

it

arises are questions still in doubt. sole cause of paresis, as long as it

Syphilis cannot be the does not exist in more than

thirty-four to sixty-five per cent, of the cases.
paresis,

Furthermore,

anatomically, is not a simple syphilitic process. the late manifestations of syphilis arise within a comAgain paratively short time after primary symptoms, while paresis

does not develop until ten or more years have elapsed after the initial lesion. Taking into consideration all of these
facts,

the only acceptable view

is

that in a considerable

number

of cases syphilis somehow produces a profound change metabolism which in turn gives rise to a toxin, which secondof ary product is the direct cause of the pathological changes char-

Other apparent etiological factors, as, alcohol, head injury, lead, and excesses, may bear a similar causal relation to this disturbance of metabolism.
acteristic of

dementia paralytica.

The pathological changes here Pathological Anatomy. enumerated can, as a whole, be regarded as pathognomic of this disease. Hyperostoses and exostoses of the cranium
with, but more especially without, thickening of the tables, are occasionally present. The dura is usually adherent to

1

the
1

calvarium

in

places.

Pachymeningitis
;

interna
.

and

215.

f. Psy., IV, 413 Allgem. Zeitschr. f Psy., LX, Nacke, ebenda, LVII, 619. Cramer, Handbuch der pathol. Anatomie des Nervensystems von Flatau-Jacobsohn-Minor, 1470, 1903.

Nissl, Monatsschr.

DEMENTIA PARALYTICA
hematoma
are

281
is

common.

The

false

membrane

almost

always situated on the vertex over the frontal, parietal, or

temporal lobes, and is of varying thickness, from a thin, almost imperceptible rust-colored membrane, to a thick,
firm, white

membrane, with small or

large, fresh or partially

absorbed

clots.

The pia is thickened, whitish, and translucent along the vessels, and especially over the vertex of the frontal and parietal lobes and the first three temporal convolutions, and rarely over the occipital lobes. The internal surfaces of the frontal poles are often adherent. The leptomeningitis is always more intense over the poles of the frontal lobes. The Pacchionian granulations are usually increased in size. The pia over the atrophied convolutions and broadened The confissures often contains blebs filled with serum.
volutions are atrophied, especially in the frontal lobes.

In

these portions the cortex is narrow and often strongly adherent to the pia, tearing upon its removal. In the other portions of the cortex, and in the basal ganglia, the atrophy
is

much

less

marked.

The

ventricles are dilated,

and the
t

choroid plexuses may contain many cysts. The ependyma especially of the fourth ventricle, and the inner walls of the

which give the usual surfaces a frosted appearance. These granulaglistening tions are composed of an increase of neuroglia, which in
lateral ventricles, present granulations,

many

cases

^has

undergone

hyaline

degeneration.

weight of the brain is regularly below normal, and in cases of long duration may be reduced to nine hundred

The some

grammes.
to thirteen

The average weight
hundred grammes.
1

is

eleven hundred

and

sixty

Microscopically,
1

nerve

cell

changes of varying intensity

Binswanger, Die Pathologische Histologie der GrosshirnrindenErkrankungen bei der allgemeinen progressive!! Paralyse, 1893. Nissl,

282

FORMS OF MENTAL DISEASE
None
of these cell changes are

are found in the cortex.

pathognomonic

for paresis.

Many,

especially the acute alter-

ation (see Plate 4, Figure 2), apparently represent a destructive process, while in others, as, for instance, the chronic

change

cell

sclerosis

(see

Plate

4,

Figure

5),

the

cell

may persist for some time. Furthermore, in cells giving evidence of sclerosis, there may also appear evidences of a
grave alteration (see Plate 4, Figure 3) apparently leads to absolute destruction of the cell. Undoubtedly also the acute and the chronic changes

superimposed acute change.

The

can terminate in a destruction of the

cell.

Of

all

the

cell

changes only the acute alteration involves uniformly the entire cortex. Both the extent and the intensity of the
destructive processes are apt to vary. There is least involvement of the occipital lobe, especially in the calcarine
area,

and

central.

of the central convolutions, particularly the preFurthermore, in a disease area, normal cells may

be found lying side by side with altered cells. In all cases there is involvement of the greater portion of the cortex, but
only in the severe or prolonged cases are all of the cortical cells diseased. The nerve fibres in the cortex and corona
suffer

atrophy in proportion to the extent of the degenera-

tion in the cortical neurones.

Where the

clinical course

has been prolonged and the neurones are much degenerated there remain but a very few normal fibres. Similar destruction of the nerve fibres

may be found in senile dementia
it is

and

epileptic insanity,

but

not as far advanced as in

dementia paralytica.

As the

result of the degeneration of the nerve cells
is

and

their processes, there

an atrophy

of the cortex,
its

extreme cases

may

shrink to one-half

which in normal width.
f.

Archiv f. Psy., Bd. 28, S. 989. Bd. 53, S. 172.

Heilbronner, Allgem. Zeitschr.

Psy.,

FIG. 3

FIG. 1

FIG. 2

FIG. 6

Fig. 1

Acute alteration in dementia paralarge pyramidal cell. Fig. 2 Plasma cells Grave alteration in dementia paralytica. Fig. 4 Fig. 3 crowded about a vessel in dementia paralytica. Fig. 5 Chronic cell change in

Normal

lytica.

dementia paralytica.

Fig. G

Rod-shaped

cell in

dementia paralytica.

DEMENTIA PARALYTICA
This degeneration

283

may be more marked about

the vessels.

are no longer arranged uniformly, but are turned in all directions, either closely pressed together, as seen in Figure 3, Plate 5, or surrounded by areas comcells

The remaining

walls.

posed only of sclerotic tissue and vessels with thickened Figure 3 should be compared with the normal cortex
2.

as represented in Figure
characteristic of paresis.

The

This anatomical picture is most cell changes already described
all

may

be found in other conditions, but in none do

the

elements of the cortex suffer to such a profound degree as here. In senile dementia, idiocy, and even in dementia
prsecox,

many

cells

and

fibres are destroyed,

but the general

conformation of the remaining elements is undisturbed. This distortion with the presence of scar tissue is present to a recognizable extent in dementia paralytica, even when the
process is not far advanced. In the areas of degeneration there may be a considerable increase in the neuroglia tissue, in which spider cells take a

prominent part, appearing especially in the deeper cell This great layers of the cortex and about blood vessels.
increase of spider cells may be seen in Figures 5 and 6, Plate 5, in comparison with Figure 4, which represents the neuroglia present in the normal cortex. The increase in

neuroglia does not necessarily correspond to the destruction of nerve cells, as normal nerve cells are often surrounded

by considerable
areas
all

neuroglia, and,
cells

the nerve

may

on the other hand, in some have disappeared without an

appreciable increase of the neuroglia. Vascular lesions in the cortex form a prominent part in the microscopical picture. The vessels are increased in

number and their walls thickened, as may be seen in Plate 5, Figure 3. Some of the vessels are dilated, a few totally obliterated, and others show small aneurisms; but the

284

FORMS OF MENTAL DISEASE
is

characteristic feature of this vascular change

the

infiltra-

tion of the perilymph spaces with ordinary

lymph

cells

and

particularly plasma cells (see Plate 4, Figure 4), the latter of which may be regarded as distinctive of paresis, since they are

Furthermore, the rarely found in other disease processes. of these cells stands in rather definite relationship prevalence
to the extent of the disease process. in the acute stages of the disease

They are most prevalent and later may disappear.
is

Another form of
cell first

cell,

distinctive of paresis,
4,

the rod-shaped

Figure 6). The cell is long and narrow, sometimes curved, with a clear nucleus and one or more nucleoli. These cells are found in large
described by Nissl (see Plate
in proximity to blood vessels and lying to the long axis of the large nerve cells. parallel In addition to the finer microscopic changes in the cortex, one occasionally finds small areas of softening, which are

numbers mostly

discernible

by the readiness with which

either the superficial

layers of the cortex or the entire cortex are detached

from

the white matter.

expect countered.
others
*

to

Gross focal lesions, such as one might accompany paralytic attacks, are rarely en-

On the other hand, Lissauer, Starlinger, and have pointed out that in the cases with circum-

scribed paralyses, hemianopsia, word blindness, and aphasia there really are present corresponding definite circumscribed disease areas in the cortex with recognizable

secondary degeneration in the corona, basal ganglia, pons,

and cord. The basal

and cerebellum also present degeneration of the nerve cells and fibre tracts. Weigert has demonstrated an increase of neuroglia in the
ganglia, central gray matter,

granular layer of the cerebellum, with a destruction of the Purkinje cells and their processes. The cranial nerve nuclei
1

Starlinger, Monatsschr.

f.

Psy., VII, 1; Storch, ebenda, IX, 401.

MU

;

^-lSlill
.'V -;;'

V-.V

:--'". .V ..'";*.*-o,

1

;.>:-. -V.a?--"

,v r

*

FIG. 1

FIG. G
FIG. 4

Normal cerebral cortex. Fig. 3 CereCerebral cortex in idiocy. Fig. 2 Fig. 1 Glia in normal cerebral cortex. bral cortex in dementia paralytica. Fig. 4 Glosis with presence of spider cells in cortex in dementia paralytica. Fig. 5 Showing the relation of spider cells with vessel walls in deep layers of Fig. (5
cerebral cortex in dementia paralytica.

DEMENTIA PARALYTICA
of the medulla
cortical cells.

285

show
l

similar changes to those seen in the

is involved to a greater or less extent in the most important lesion being degeneraalmost tion of the fibre tracts in the posterior and lateral columns.

The

spinal cord
all cases,

Degenerative changes are occasionally found in the peIn the internal organs vascular changes ripheral nerves. are so frequently found that they seem to bear a definite

Of these, atheroma of relationship to the disease process. the aorta and arteritis of the vessels of the liver and kidneys
are the most prominent.

Symptomatology.

From

the onset of the disease there

is

increasing difficulty of apprehension of external impressions. Patients are unable to grasp clearly and sharply the char-

acter of the environment.

to recognize former well-known objects,

Later they mistake persons, fail and overlook im-

portant details. Attention is maintained with effort. Long and complicated sentences are not comprehended, and they often miss the connection of things. Customary duties are performed with difficulty and often incorrectly. Thus, there
develops a clouding of consciousness; the patients live a dreamy existence, as if constantly under the influence of liquor.

an important diagnostic sign. Later the disorientation increases. The patients may answer questions quite correctly and upon superficial examination seem to conduct themselves in accord with their environment ; but at the same time they neither know where they are, with whom they are speaking, nor the significance of what is
This condition of torpor
is

taking place about them. They fail to recognize the season or the time of day. A patient may say that it is summer
Westphal, Allgem. Zeitschr. f. Psy., Bd. 20-21. Westphal, Archiv H. I., Bd. 12. Westphal, Virchow's Archiv, Bd. 39. Fuestner, Archiv f. Psy., Bd. 24. 1.
Psy.,
1

f.

286
while leaning

FORMS OF MENTAL DISEASE
upon a hot radiator and looking out upon a
This condition
finally reaches

snow-covered landscape.
of absolute disorientation,

one

when

the patients cannot perceive

any external impressions. At the onset of the disease there is usually an increase of The patients tire easily at their acthe sense of fatigue. customed duties and require more frequent and longer Hallucinations play an unimportant part. periods of rest. In the greater number of cases none appear, but in some cases there exist for some time very many hallucinations of
or elaborate
all senses.

Again the

clinical picture

of the acute alcoholic hallucinosis.

be very like that Hallucinations of sight

may

Hallucinaare often present in patients with optic atrophy. tions of touch in connection with delusions of influence are

not infrequent.

memory are very characteristic and are the most prominent of the mental symptoms. The among memory at first becomes defective for recent and passing
defects of

The

events.

This defect

is

the patients,
for

who complain
it.

sometimes keenly appreciated by of and sometimes devise means

correcting
defective.

Later,

memory becomes
is

more

The memory

progressively especially defective in the

temporal arrangement of experience, and the patients fail to recall the time of the occurrence of events. They cannot
inform you when the mail arrived, when they had breakfast, or when they last saw you. These patients may live so
completely in the present moment that they may ask several times a day where they are, how long they have been there, or if they have ever seen you before. The early events of
life

are comparatively well retained for some time, the patients being able to tell of their occupation, former places
of residence,

and events

of their childhood.

This remote
also the

memory

also suffers late in the disease,

and here

DEMENTIA PARALYTICA
time element
is

287

the

first

to be affected.

Dates of marriage,
for-

births of children,

and important events are completely

gotten.
of

and even the names
memory, when
forgotten,

Finally they are unable to recall the place of birth of their parents and children. Lapses

may

definite periods of time are completely occur following epileptiform or apoplecti-

form

seizures.
store of ideas

The

terminating in a complete destruction of all the

undergoes a progressive impoverishment, mental

The rapidity of this process varies with the possessions. of the disease and the power of resistance as well intensity
as the intelligence of the individual. The more intelligent resist longer, and the most frequented paths of thought are retained longest. As memory fails, its place in the intellectual
life is

often

made good by

reminiscences
enters the

disappear,

the imagination. As real invention runs riot. Whatever

mind is related as genuine; stories, or what may have been told them by another, become a part of their own experience. The patient relates that he was in a terrible
railroad accident last night, in which a dozen were killed;

he led the troops at San Juan; yesterday he had a conference with the British ambassador. He has captured a hundred beautiful women from a Turkish harem, and discovered a

new and

inexpensive motive power for automobiles. These dreamlike fabrications are most pronounced in cases of optic atrophy. Very often such fabrications are used in
the gaps in recent memory. They can be brought out and influenced by suggestion on the part of the listener.
filling in

The
all

patient may be somewhat dubious at first when expressthese absurd reminiscences, but at the next interview ing

doubt

will

memory

to

have disappeared. external influences
of

is

This susceptibility of the a part of the general
Their ideas

susceptibility

thought of the patients.

288

FORMS OF MENTAL DISEASE
and
fail

are never firmly grounded,

to exert a lasting influ-

ence upon their thoughts and actions. Any accidental impulse suffices to distract and lead them into another
channel.

Impairment of judgment is another very prominent symptom. It may be the first to call attention to the disease.
Objects of former criticism

The former conservative
business
life

to arouse comment. which have made their principles
fail

now

a success are

lost sight of,

unity and system.
senseless

Weighty

obstacles are overlooked

and new plans lack and
Business

schemes produced with perfect serenity.

and

standards are completely disregarded. Their conceptions have no bearing upon the environment, but center almost entirely about themselves, so that they come
social

to live in a sort of

upon
sions,

their

own

ideas

dream world, in which everything depends and wishes. The formation of deluresults

which partially

from

varies

much

in different cases.

this defect of judgment, In some there are but few

delusions, but in most cases the delusions form a prominent feature in the early stages of the disease. These delusions are transitory, unstable, without system, and show confusion

and incoherence. They are characterized by vagaries, senseIt only lessness, numerous variations, and contradictions.
rarely stable
It is

happens that for short periods the delusions are and uniform like those of paranoia.

not unusual at the onset for the patients to express some insight into their mental disease, complaining of their
failing

memory,

irritability,

and increasing

difficulty of

thought.

Later, with increasing deterioration, all genuine The patients then usually exhibit a feelinsight disappears.

ing of well-being; they claim that they never felt stronger or more vigorous mentally. At times during the course of

the disease the patients

may make various hypochondriacal

DEMENTIA PARALYTICA

289

complaints, but even then they fail to recognize the real physical symptoms of the disease.

The emotional
first

life

shows a profound disturbance.

At

The patients are is usually increased irritability. disturbed at home and work, are sullen, peevish, and easily apt to show considerable passion at trifling annoyances, and
there

completely lose control of themselves.

they

may

the other hand, show an unusual insensibility to the claims
to

On

of others, indicative of the deterioration of the finer feelings.

They then

fail

show sympathy at the

suffering of their

children, are indifferent to immoral surroundings, and do not take their wonted pleasure in reading or professional

pursuits.

The emotional

attitude
it is

is

much

in accord with the char-

acter of the delusions;

elated with expansive, or dejected with depressing delusions. Later the emotional tone becomes very unstable, and there are frequent and abrupt

changes.

In the midst of laughter they
tears, or misery

may break

out in

a storm of

These changes of emotion

be brought by simple sugor by raising or lowering the tone of voice, or even gestions

may may

give

way

to silly happiness.

by the expression

of the face.

A

complaining that he had lost all blood and could not breathe, when tickled in the ribs and

patient lying on the floor, his organs, that he had no

asked

how he

felt,

feeling fine;

come

" I am exclaimed, beginning to laugh, and see me again/' In the demented

forms of the disease, where there may be only a few delusions, no especial emotions are shown, the patients being in a condition of simple joy or irritable dissatisfaction most of
the time.

There
stability

is

a profound change
will

of disposition;

the former
to progres-

and independence

of action give

way

sive

weakness of the

power.

The

patients

become very

290
tractable,

FORMS OF MENTAL DISEASE
but occasionally

may

be extremely stubborn.

Early in the disease they are led to indulge in all sorts of excesses and sometimes persuaded to deed away property.

angered and determined to commit an assault upon some one, they may be easily influenced to desist by a simple
suggestion.

When

window

patient about to leap from a third-story because of fear, was readily prevented by the sugit

A

gestion that

would be better to go down and jump up. Any impulse that arises may be acted upon without referaccomplishment. One patient is said to have stepped out from a second-story window for the purpose of picking up a cigar stump.
ence to the extreme difficulty of
its

of

In conduct, the patients show a disregard for the demands custom and law, are unconstrained, and often commit

grave offences into which they have no insight. As a reason for such conduct, they often say that they acted so because
it

happened to come into their minds. The social restraints normally imposed upon one by the environment

never interfere with the carrying out of their wishes.
are quite reckless of personal safety,

They
injure

and occasionally

themselves severely in their foolhardy actions. In conditions of great clouding of consciousness or in advanced
deterioration there are sometimes present some symptoms characteristic of the catatonic form of dementia prsecox,

such as catalepsy, verbigeration, negativism, and stereotyped movements; but these are transitory and change more readily and frequently than in catatonia.
Physical Symptoms.
in both the

The

physical signs of the disease,

motor and the sensory fields, are as extensive and profound as the psychical. These may appear either before the mental symptoms or not until dementia has become well advanced; usually they are coincident. Of the sensory symptoms, headache is often the first to

DEMENTIA PARALYTICA

291

appear, accompanied by a feeling of pressure as if the head were being held in a vice, together with ringing in the ears and dizziness. The special senses at first give evidence of
excitation,

which

later subsides into a state of insensibility

corresponding closely in degree to the stage of deterioration. Some patients have difficulty in the recognition and localization of objects held before them, which by Fuerstner is ascribed to involvement of the occipital cortex. Word blindness and asymbolism are often observed. Hemiaattacks.

nopsia occasionally follows apoplectiform or epileptiform Optic atrophy is found in five to twelve per cent,
of the cases.

Disturbances of the senses of taste and smell
loss of the

have also been observed by some, especially the
sense of taste for saline solutions.

The disturbance

of the

cutaneous sensations

is

quite often prominent; at

first

there

uncomfortable sensations, burning or drawing sensations, rheumatic pains, etc. Hence, many patients are for a long time regarded as neurastheniacs. In

may be

all sorts of

an increased sensitiveness to cold. Later analgesia appears, which may be so pronounced that needles

some

cases there

is

through a limb without pain. Finally, the patients may pull out their hair, disturb an open wound, draw out their toe-nails, and persist in mangling
can be thrust
entirely

their

own

flesh.

Of the motor symptoms paralytic attacks, mostly epileptiform or apoplectiform, are very important, occurring in from forty-six to sixty per cent, of cases. The attacks may
only of a transitory dizziness with perhaps an inability to speak. Attacks of this sort are often the first symptoms to call attention to the disease.

be very

light, consisting

Occasionally the attack consists of a suddenly developing

aphasia lasting several days, unaccompanied by paralysis. In the epileptiform attacks, which may be either of the

292

FORMS OF MENTAL DISEASE

Jacksonian or of the ordinary type, confusion or stupidity may usher in the attacks, which begin with a fall to the
floor,

loss

of

usually Clonic movements predominate and are often synchronous with the pulse. Convulsive movements may be confined to

in

consciousness, and convulsive movements, one limb, extending gradually to the others.

a single group of muscles or to one limb. The duration of the attack is from one to several hours, but sometimes
clonic

movements

of varying intensity continue in

one or

more limbs
cus,
daily,

for days.

A

condition similar to status epilepti-

where there are from twenty to one hundred attacks

persist for days, often terminating in death. the attacks the temperature is often febrile, the During urine frequently contains albumen, and there may be reten-

may

and feces, as well as paralysis of the muscles of The fatal termination is usually due to aspiradeglutition. tion pneumonia. The attacks pass off slowly, sometimes
tion of urine

leaving the patients in a condition of confusion. In the earlier stages of the psychosis, these attacks leave the

more profound deterioration, and sometimes also with signs of transient aphasia, hemiplegia,
patients in a condition of

hemianopsia, convulsive movements, or areas of anaesthesia. Apopkctiform attacks often occur, and may be the first

important sign of the disease.

In these attacks there

is

the usual loss of consciousness and stertorous breathing, with occasional high elevation of temperature, accompanied

by hemiplegia and aphasia.
loss

In some attacks there

is

no

of

consciousness,

transitory paralysis.
similarly appear;

simply the sudden appearance of Transitory sensory disturbances can
paraesthesias, anaesthesias, or

as, severe

defects of vision.

It is a distinguishing feature of these

apoplectiform attacks that the paralysis disappears quickly and without evident residuals. Other somewhat similar

DEMENTIA PARALYTICA

293

attacks, occurring in the course of the disease, are those in which there is a sudden development of extreme confusion,

with motor restlessness,

difficult speech, flushing of

the face

and body, vomiting, and high temperature. These last from a few hours to a few days and pass away quickly, leaving the
patient in his former state. The frequency of the apoplectiform and epileptifonn attacks depends somewhat upon the character of the treat-

ment.
cesses

They may result from emotional disturbances, exin eating, and especially from an accumulation of feces
appear without evident

hi the rectum, but they frequently

Bed treatment, regularly, reduces then- frequency. occur most often hi the demented form of the disease. They Motor disturbances of the eye include transitory paralysis
cause.
of single muscles (eighteen per cent, of the cases) and rarely complete ophthalmoplegia. Differences of the pupil occur
in

about fifty-seven to eighty-three per cent, of the immobile pupils in from thirty-four to sixty-eight per
sluggish reaction to light hi thirty-five

cases,
cent.,

and

and

five-tenths

per cent. (Argyll-Robertson pupil).

The musdes of the face lose their tone, the nasolabial fold and other lines of expression disappear, and the countenance becomes expressionless. This washed-out, expressionless
well represented by the group of three paretics seen hi Plate 6. Lack of tone in the muscular system is also seen in their slouching and inelastic
is

character of the countenance

attitude.

There

is

also a loss of control of the muscles,

giving rise to

incoodination, noticeable mostly

when the

mouth or
muscles
is

eyes are forcibly opened.

A

fine

tremor of these

almost always present. The voice loses its characteristic tone and becomes monotonous. Tremor of the
tongue, which
retractive, is

either finely fibrillary or coarse and a constant sign. In advanced cases there is

may be

294

FORMS OF MENTAL DISEASE

often a rolling of the tongue about the mouth as if it were a quid. This in some cases has been explained by the presence
of areas of anaesthesia in the of the teeth
is

occasionally

mucous membrane. Gritting associated with these movements

of the tongue, or

may be present alone. Disturbances of speech are among the most characteristic
They are

either aphasic or articulatory. often appears after paralytic attacks. Transitory aphasia Paraphasia, which may appear at the same time, is more per-

symptoms.

and sometimes lasts several months. Word blindness and word deafness are rarely encountered. There is occasistent

sionally

agrammatism, as seen

in the misuse of infinitives

of conjunctions. There may be an elision of as in the use of elexity for electricity, or a redusyllables, plication of syllables, as electricicity, and finally there may

and omission

be tendency to repeat

syllables,

forming a genuine word

clonus, as Massachusetts-etts-etts-etts.

Disturbances of articulation are more frequent. They may follow paralytic attacks, but more often occur in-

dependently of them.

As the

result of difficulty in

move-

ment of the lips and tongue frequent pauses are made between syllables or words and when hesitating speech accompanied by a fall in the tone of voice produce a scanning speech. Gliding over the poorly articulated sounds gives rise to an indistinct and slurring speech. These difficulties
lead to the substitution of words or syllables similar in sound but more easily pronounced, or to the elision of difficult syllables.

Many

patients, in their efforts to

overcome

The

these difficulties, stutter and produce an explosive speech. patients often appreciate the difficulties of speech, but

are ready to explain them by dryness of the mouth or loss of teeth. Speech disturbances are readily observed in ordinary conversation. The test words and phrases, if used,

DEMENTIA PARALYTICA

295

attention

should be introduced into long sentences, because, if the is concentrated upon single words, they may be pronounced correctly. Words and phrases used for this

purpose are: electricity, national intelligency, methodist episcopal, ninth riding Massachusetts artillery brigade, etc.

The
elicited

central

and ataxic speech disturbances are best

by asking the patients to read aloud. Writing usually shows defects similar to those noticed in speech, but they are proportionately more prominent (Plates 7 and 8). Patients, on the other hand, who speak clearly may produce on paper an unintelligible muddle of words and syllables. In advanced cases there is complete agraphia (Plate 7, Figures 2 and 3). The patients are then able to make but a few unintelligible marks, and may even give up without making
a
sign.

The handwriting

is

characterized

by

irregularities

caused by the tremor, excessive pressure on the pen, and carelessness. The irregularities are more extensive than in
the case of the senile, whose lines regular tremor.

show the

effect of

a

fine

Ataxia appears
delicate

first

of all in those finer

movements such
Later the more

as are employed by skilled workmen.

movements in locomotion, such as turning about quickly, become ataxic. The clothing cannot be readily buttoned, the gait becomes unsteady, swaying and shuffling.
In from sixteen to twenty-four per cent, of the cases of paresis there are tabetic signs; such as, loss of reflexes,
ataxia,

Romberg

sign, paralysis of the

rectum and bladder,

and occasionally

girdle symptoms, lancinating pains, and crises. In from six to eight per cent, of cases, genuine tabes antedates for several years the appearance of the paretic

symptoms (ascending
1

1 paresis or tabo-paresis).

In about

die spinalen

Cotton, Amer. Jour, of Insanity, Vol. 61, p. 581. Gaupp, Uber Symptome der progressiven Paralyse, 1898. Torkel, Besteht

296

FORMS OF MENTAL DISEASE

fourteen per cent, of the cases of paresis there are evidences of involvement of the lateral column of the cord, as shown

by the spastic paralyses. In many cases spastic and tabetic symptoms are variously combined. Intention tremor may be present, and in a few cases choreiform movements are marked enough to simulate Huntingdon's chorea. Later in the course of the disease the patients become bedridden and often develop contractures and muscular atrophy. The body also tends to assume a curved position with a fixed tension of the muscles of the neck so that the head is thrown forward and the body does not rest upon the bed throughout
its

entire length.

During

this stage of

the disease

is occasionally noticed convulsive movements of the individual muscle groups, especially during active and pas-

there

sive

movements, but also when the muscles are at

rest.
1

pressure of the spinal fluid, according to Schaefer, is increased in two-thirds of the cases from normal (40 to

The

70 millimetres) to 150-380 millimetres.
finds that the

Furthermore, he

albumen is increased and contains serum albumin, while the normal fluid contains only globulin. The microscopical examination of fluid shows a lymphocytosis
(see p. 103).

The tendon

reflexes are usually exaggerated,

sometimes so markedly that the entire body shakes when the tendon is struck. Frequently the exaggeration diminishes,

twenty to thirty per cent, of the advanced cases the reflexes are lost. In eighteen per cent, of the cases there is
in

and

a difference in the two sides.
is

The

loss of the patellar reflexes

Babinski reflex

usually associated with immobile pupils and myosis. The is often elicited in connection with spastic

eine gesetzmassige Verschiedenheit in Verlaufsart und Dauer d. progressiven Paralyse nach d. Charakter d. begleitenden Rmaffektion ? Diss., Marburg, 1903.
1

Schaefer, Allgem. Zeitschr.

f.

Psy.,

LIX,

84.

ft

FIG.

1

Fia. 2

PLATE

7

Fig. 1 shows, besides the excessive pressure elision, substitution of letters and syllables. The patient has attempted to write from dictation, " Around the rugged rock the ragged rascal ran."
Figs. 2
patients, after an attempt to write, simply laid the pen

and 3 represent conditions which approach complete agraphia, down.

in

which the

DEMENTIA PARALYTICA
symptoms.
creased at

297

The

electrical irritability of the

muscles

is in-

Disturbances of the first, but later diminished. bladder are often present, both retention and incontinence,
the latter usually being the result of the former. Sluggishness of the bowels may extend to obstinate constipation.
Finally in the end stages there is paralysis of both sphincters. The sexual power may be increased at the onset, but later The vasomotor disturbances consist of it is diminished.

erythema, persistent blushing of the skin, rush of blood to the head, dermographia, and cyanosis. The so-called trophic changes, acute decubitus, increased fragility of the ribs,

and othematoma, stand in close relation to the vasomotor changes, and are of frequent occurrence. Furthermore, there is a loss of vitality and of the power of repair in all tissues, so that a very trifling injury may lead to an extensive
lesion.

Acute decubitus once started

is difficult

to heal.

temperature during the course of the disease is mostly normal, except toward the end, when it is apt to be sub-

The

normal.

A

striking peculiarity

is

the excessive elevation of

trifling disturbances, such as mild bronoverdistention of the bladder, or obstinate constipachitis, There is often a rise of temperature during paralytic tion.

temperature with

attacks,

as already mentioned, there may be short periods of a few hours or more of an excessively high temperature apparently without adequate cause.

and

finally,

The sleep is usually somewhat disturbed during the first stage and more so during the second, where there is motor
excitement, but in the last stage the patients are sluggish and may sleep much of the time. This varies, however, as
in

some

cases the patients

may, from the onset, show a

tendency to sleep continually, while in other cases insomnia The appetite suffers persists throughout the whole course. at first and during excitement, but later the patients eat

298
well.

FORMS OF MENTAL DISEASE

The condition of nutrition is poor until excitement subsides and deterioration is well advanced, when there is

usually an increase in weight, which

may

last until death.

loss of appetite and impaired nutrition coexist, to extreme emaciation. leading Occasionally albumen and l sugar are present in the urine. The blood changes consist

Sometimes

moderate and progressive anaemia, in which the fall in haemoglobin is most marked, a progressive increase of the
of a

polymorphoneuclear leucocytes reaching its highest point during the terminal state, and a transitory leucocytosis

accompanying paralytic attacks. D'Abundo has called 2 attention to an increased toxicity of the blood, and Idelsohn
finds that the blood of paretics in a considerable proportion

of cases inhibits or prevents the

growth of cultures of

bacteria.

The mental and physical symptoms enumerated above represent in general the clinical picture. The grouping of
the individual symptoms, however, varies widely in different This has led to the recognition of four types of cases cases.
:

the demented, expansive, agitated, and depressive, each of

which presents a somewhat different course from the onset. The deviations from these types deter many from the
acceptance of this differentiation, but its value becomes apparent in a considerable number of cases where one is
able to forecast the future duration of the disease

and the

character of

many

of the

symptoms.

The demented form, because of the simple deterioration, unaccompanied by many delusions and hallucinations, its rapid course without remissions, and the relative frequency
of its occurrence should be regarded as the type of the
Diefendorf, Amer. Jour. Med. Amer. Jour. Med. Sc., 1897.
2 1

Sciences, Vol. 126, p. 1047.
640,

Capps,

Tdelsohn, Archiv f . Psy.,

XXXI,

^
TS -3

w

9 a

ii

DEMENTIA PARALYTICA
disease.

299

The

clinical picture of

megalomania, which has

been and
until
it is

still is,

disease, has in

by some, regarded as the prototype of the recent years become less and less prominent,
in less

now encountered

than twenty-five per cent,

of cases.

DEMENTED FORM
The demented farm
is characterized

by gradually progres-

sive mental deterioration without
tions, delusions, or great

prominence of either hallucina-

psychomotor disturbance. Transitory periods of delirious excitement, of anxious unrest with hypochondriacal ideas of depression, delusional states, or periods

megalomania may occur in this picture, but they are insignificant when compared with the rapid advance of profound deterioration. The onset of this form is very gradual. The symptoms at
of
first

may

resemble those of neurasthenia; patients complain

of inability to apply themselves to work, loss of energy,
indefinite pains, feeling of pressure in the head,

and

irri-

tability. They are forgetful and flighty, at times drowsy, and at others somewhat confused. Soon mental deteriora-

becomes apparent in the inability to explain their actions, in errors of judgment, failure of memory, and absence of the usual moral feelings. Their work is irksome, and they occasionally fall asleep over it. They forget to
tion

go to meals, make mistakes in

figures,

and overlook im-

portant matters. They are usually good-natured, tractable, are easily led astray, and often drink to intoxication. In

some cases, however, they become obstinate and self-willed. The household suffers, dinner is uncooked or improperly Patients are seasoned, and the children are neglected. reckless and may even act in opposition to established preThe consciousness soon becomes clouded and the cepts.

300
patients
lose
fail

FORMS OF MENTAL DISEASE
to thoroughly

comprehend their environment, account of time, get confused as to place, and mistake persons. They may even get confused in their own home

and not recognize

friends

and

relatives.

Transitory hallucinations and delusions may appear, but the latter are very weak, childish, arid easily influenced by

Occasionally there are weak attempts at fabrication. During the early stages there may be some anxiety with weeping and praying, and frequently also an increased
suggestion.
irritability,

some sexual excitement,

aggressiveness,
is

and

assaults; but the characteristic emotional change

a pro-

gressive deterioration of the feelings. The patients become increasingly dull and apathetic. They are perfectly con-

tented wherever placed as long as the simplest needs are satisfied; such as, food, drink, and tobacco. They have a

complacent smile when addressed, greet strangers very Often at first cordially, and are friendly with every one.
is some insight when the patients complain of slowness of thought and failure of memory, but the increasing deterioration obscures this feeble capacity. On the other

there

}

hand, they

may

express a feeling of well-being

and

perfect

confidence in their business capacity.
capacity for work suffers soon. The patients become careless in their duties, forget engagements, allow letters to

The

go unanswered, go to work at all hours, and finally stay away altogether. A few patients may struggle along with
their work, realizing

and worrying over

difficulties

and

fre-

quent errors, while others neglect their occupation to look after all sorts of unnecessary and unprofitable affairs. They

may become

restless,

wandering aimlessly about, indulging

in excesses or

committing petty crimes.

They lack

will

power, are easily led astray, are unable to care for themselves, forget when to go to meals, and neglect their per-

DEMENTIA PARALYTICA
sonal appearance.

301

On

inaccessible, repulsive,

and

the contrary, some patients are surly, answering questions as

if angry, rebuffing friendly advances, and opposing without reason anything desired of them.

A few patients,

in spite of

tion, present a good demeanor.

an advanced stage of They greet one

deterioracorrectly,

and appear perfectly at ease in talking about themselves, but at the same time are disoriented, and are unable to give any coherent account of their lives. The patients usually enjoy a good appetite, sleep well, and are the picture of The mental deterioration may have been so gradual health. and so unobtrusive that the friends and relatives fail to
appreciate the profound degree of deterioration exhibited.

This form of dementia paralytica embraces forty per cent, of the cases admitted to institutions. Paralytic attacks
occur in almost one-half of the cases.
frequent than
in the other forms.

Remissions are

less

half of the cases

The duration in almost does not extend beyond two years. In
first

eighteen per cent, of the cases death ensues within the year, and it is very rare that the disease lasts five years.

EXPANSIVE FORM

The expansive form
of

is characterized

by great prominence
course,

expansive delusions, a

prolonged

and

greater

prevalence of remissions. The onset is usually gradual, with change of character, difficulty of mental application, signs of failing memory and

judgment,
physical

increased

irritability,
spells,

and, in

addition,

such
dis-

signs

as fainting

transitory speech

turbances, syncopal attacks, the onset is quite sudden.

and headaches.

Occasionally

Following these prodromal symptoms, there

may

first

302

FORMS OF MENTAL DISEASE

develop the picture of the depressed type with delusions of
persecution, self-accusation, and anxiety, but usually from the onset there is a condition of excitement with elation,

which transitory states of depression with weeping may occur. In case there have been signs of despondency and illness, these then disappear

and grandiose

delusions, during

deand the patients gradually occasionally suddenly a marked feeling of well-being; they are bright, velop They busy themselves affable, talkative, and energetic. with new and elaborate schemes for getting wealthy, stake out property, and draw designs for wonderful machines.

They
and
at

are busy from early morning to late at night, soliciting patronage, ordering large quantities of material for building
for other purposes.

first

are

The numerous expansive delusions within the range of possibility and may appear

attractive to the unsuspecting, but soon pass into the realm of absurd imagination, reminding one very much of the
prattle of children.

These, with the restlessness, present

the characteristic picture of megalomania. The patients claim never to have felt better in their lives, can lift tons,

can whip the best man on earth, have the strength of a thousand horses, and can move a train.

They believe their English the best; they speak as fluently several other languages; their voice is clear and distinct and can be heard for many blocks, because of its excellent
qualities.

compose
subject.

inspiration to write a book; can beautiful poems; can deliver an oration on any

They have the

associate only with the most cultured people; only the genuine blue blood courses through their veins; they are going to build a marble mansion at Newport, and

They

have a floating palace. Business is flourishing; they are " mint of money/' have several gangs of men making a for them, and still there is more work than they working

DEMENTIA PARALYTICA

303

can attend to; besides their regular business, chickens are being raised by a special method at an enormous profit;
they have secured rich gold claims in Nevada, which are doubling in wealth daily.

and

Formerly they were brakemen, but now run the fastest finest train in the world from New York to Chicago without a single stop, allowing none but millionnaires to ride;

besides a profitable law business, they are now engaged in writing a novel which will startle the world, and for which they have received priceless offers from publishers in this

country and in Europe.
ful

A ship carpenter developed wonder-

power

in a vessel

in his eyes, so that he could detect defective wood by simply standing in the hold and looking out-

ward, and for this reason he was appointed detective of a marine insurance company, and had travelled all over the

world inspecting vessels. He had become so wealthy that all the banks in the state were in his possession. A seamstress had devised a new method for cutting
dresses,

which had won her world-wide fame, having been

Europe because of her wonderful She herself could cut and sew a hundred dresses a day, and had under her five hundred girls, all of whom used gold thread. She could sew on a thousand buttons a
called to all of the courts of
success.

minute. A jockey had discovered a new way of breeding and training runners, and now from his Kentucky ranch was supplying every circuit and handicap with winners. The utter absurdities which increase from day to day are proof of the increasing mental weakness. The delusions abound in contradictions and become more incoherent, the product of a more dreamy ingenuity. The patient now
drives the largest engine in the world, drawing a thousand palace cars, all lined with gold and trimmed with pearls,

which encircles the globe every twenty-four hours, stopping

304

FORMS OF MENTAL DISEASE

only at New York, San Francisco, Calcutta, Paris, and London. He now has formed a chicken trust to extend over the

system of the be employed in hatchworld, so that only the Chinese ing the eggs. Another has a most wonderful herd of cattle,
will

whole earth, and

will reconstruct the social

whose horns are forty feet high, whose eyes are diamonds, whose feet are gold, and each cow produces five hundred
milk in twenty-four hours, the patient himself milking a thousand a day.
pails of

The

patients are the most beautiful beings that ever lived.
all of

They have married seven hundred
thousand children,
dresses;

whom

millionnaires, have twenty have gold slippers and gold

they can
castle ten

they themselves wear only diamond trimmings; fly away in the air to a world where there is a

thousand miles long filled with lovely people who do nothing but amuse themselves. They are not human, but divine; can create a universe, visit all the stars, have sent Christ to Mars; whatever they touch turns to gold.

They know

all

sciences,

are the greatest physicians in

a hospital of marble twenty stories existence; high, provided with a bar for the doctors, where the choicest wines and the best Havana cigars will be supplied; and there
will build will be a dissecting room, with a huge ice box, where ten thousand bodies can be kept all the time.

They

will build

the Chinamen here to work.

a tunnel through the earth and bring all One patient said that he was

going to build towns; that he had been to Washington to see the President, that he wanted six thousand billion gunboats, one million bomb-shell boats, one million marines, and that he would cross the ocean and blow up all of the countries and bring the people out west and put them on farms; that he would blow up the Queen's buildings, and that he

would give each one

of the marines

two bags, and each

DEMENTIA PARALYTICA
would have to go two times and diamonds.
in order to bring

305

away the

silks

These delusions are almost entirely self-centered. They may change rapidly, each day new and extravagant ideas
filled with the most glaring contrathe tendency to expansiveness is less marked. Transitory hallucinations of sight and hearing are occasionally expressed, but they never take a prominent

appearing, which are
dictions.

In

women

part in the disease picture. Consciousness is somewhat clouded during the development of the megalomania. There is usually disorientation
for time, places,

and persons,

the patients are too

much

absorbed in their numerous ideas to note the surroundings or to take account of time. Later they become acquainted
with the place and a few of the persons, but they rarely know the month, day, or the year. The content of thought is
centered entirely about
self

and the many varied delusions.

At

first it is usually coherent, although at times, in connection with great psychomotor restlessness, there may be incoherence, distractibility, and sometimes flight of ideas.

The

patients are usually talkative, and may produce a continuous stream of delusions. Incoherence of thought is
their letters.
attitude corresponds closely to the content

more evident in The emotional
contented,

of the delusions; the patients are cheerful, happy, hopeful,

and

exalted.

Everything in the environment

is

pleasing; they are in luxurious quarters, have the best of food, plenty of servants, fine clothing, fast horses, and are

associated with the finest

happens that for a short time, a few moments or hours, rarely
days, they lose spirits and become depressed, complaining of confinement, and expressing hypochondriacal delusions,

men

in the world.

It often

or

weep

bitterly because of harassing persecutions.

Even

306

FORMS OF MENTAL DISEASE

when most miserable it is often possible by suggestions to reestablish the feeling of well-being, showing the great instability of the
is

emotional condition.
itself

always present, manifesting

Increased irritability upon the slightest

provocation. Disagreements or doubts relative to their superiority or immense wealth may arouse anger or even an

Later in the course of the disease the aggressive attack. are usually in a uniform state of quiet cheerfulness patients
in spite of their bedridden condition with filthiness, paralysis,

and even
asked
"

contractures.
feels,

The

paretic

on

his deathbed,

when

how he

often drawls out with

some animation,

Fine, fine."

In the psychomotor field excitement predominates from the onset and may reach an extreme degree. At first the
patients are restless, bustling about on new and important business, remaining up until late at night, devising plans, writing many letters, and travelling about from place to
place.

They are very

talkative

and make confidants

of

every one they meet.
disease they

For short periods in the course of the may develop extreme restlessness, with insomnia,

complete clouding of consciousness, recklessness, aggressiveness, and impulsiveness. They shout from fear, mutilate
their

own

bodies,

and rush about

blindly diving into

any

obstacle.

It is impossible to attract their attention or to

get coherent answers. They fight off imaginary enemies and shout threats and curses. These conditions of excitement
rarely last longer

than a few hours or days, and disappear

gradually, usually leaving the patient in a state of profound deterioration.

more

In actions the patients soon become foolish and show a lack of judgment and moral obtuseness. They develop bad habits, smoke or swear, enjoy telling obscene stories, seek
the

company

of lascivious

women, and become

disorderly in

DEMENTIA PARALYTICA
dress

307

and careless in appearance. They may assault or commit thefts, but every action shows an absence of plan, When conrecklessness, and utter disregard for others.
fronted with their observed behavior,
it is all

denied with

perfect serenity. As the disease advances, the activity production of unintelligible letters and

is

limited to the

plans, scribbling

on paper, and collecting useless rubbish. The patients are happy and contented throughout it all, invariably asserting
with brightening countenance that they are feeling fine. " They may be heard mumbling to themselves, millions," " " fine horses," "beautiful women," mansions," grand mere relics of former ideas which now represent the last
traces of their intellectual
life.

The expansive form comprises from fifteen to sixteen per cent, of the paretics. The duration is more prolonged, less than one-third of the cases dying within two years. Some
cases even live fourteen years. Remissions occur in onethird of the cases, which in part accounts for the prolonged course. It sometimes happens that the expansive form

passes over into the depressive, and vice versa, and this may take place several times, simulating the picture of manicdepressive insanity.

AGITATED FORM

The

agitated

form

is characterized

by a relatively sudden

onset with a condition of great psychomotor excitement

and

delirium,

most extremely expansive delusions, great clouding of consciousness, and a short course. The
the presence of the

and

usual prodromal symptoms are lacking and there rapidly develops extreme megalomania. change of disposition is often noticed for a time previous to the sudden outbreak.

A

The

patients rapidly

become very

energetic,

and express a

pronounced feeling of well-being.

They

are born again,

308

FORMS OF MENTAL DISEASE

and the strength of ten thousand men ; could carry an ocean vessel or fly to the moon in a second. They have acquired all knowledge, can educate a thousand
possess the ambition

teaching them to speak every known language. They themselves are Gods, Gods over God, have created God and the universe; have been everywhere from the heights
of heaven to the depths of hell. They are now establishing a new method of reckoning time; by their decree the days are to be one thousand hours long, the weeks are to

men an hour,

contain one thousand days, and the years ten thousand

and by a new size and The world moves and stands at shall have a third eye. are interested in all wars and have their command. They marshalled huge armies. Their wealth is fabulous, more
months.
formula
to create animals,

They know how
shall

man

be increased a hundred-fold in

than any one man ever possessed before. All quantities are reckoned in the ten thousand billions; they own ten thousand
billion houses;

ten thousand billion cows; ten thou-

sand

billion acres of land, etc.

Their houses are built of
set

Italian marble, with gilded

domes

with diamonds, the

floors are of onyx, the furniture,

pure gold, and the hang-

ings, the finest fabric, trimmed with pearls and sapphires. Their ideas become more and more expansive, and finally

seem even to surpass the bounds of imagination. In the midst of these megalomanic delusions, one occasionally encounters the most extremely pessimistic ideas which
are sometimes hypochondriacal. The patients claim that they are suffering untold misery from sharp pains in the back; some one entered the room at night and disem-

bowelled them, so that the following morning they could not go to stool; miles of fine electric wires have been placed
in the flesh, about the limbs

and completely

filling

the skull,

through which

electrical currents are nightly applied, causing

DEMENTIA PARALYTICA
the flesh to burn.
ing

309

memory

be some insight into the failand the defective nutrition, which leads them

There

may

momentarily to fear that they are suffering from cancer of the most malignant type, but at the same time one is assured that they are undergoing a process of purification which will leave them healthier and mightier. Sometimes they are perplexed at their own stupidity for allowing themselves to be confined in a hospital instead of going to

to

Europe consummate a deal by which millions would have been made. Hallucinations of sight and hearing may be present, but are not prominent, and fail to influence greatly the
clinical picture.

The psychomotor
showing
are
talkative,

condition is one of great restlessness, The patients occasional impulsive movements.

sing, laugh, shout, and prattle away like over their innumerable plans and many pleaschildren ures. They are constantly in motion, going from one thing

to another, working in a planless way on various schemes, scribbling unintelligible letters to millionnaire friends, issuing to military staffs, and sending cablegrams to the different crowned heads. They have no care for themselves,

commands

neglect personal appearance, forget about eating, smear their dresses or the walls with the food placed before them,

masturbate, and expose themselves indecently.

Thought is usually incoherent, and there is often observed a flight of ideas. Emotionally, there is a marked irritability,

and

interference quickly leads to outbursts of passion, with cursing, threats, and aggressiveness; but elation predomiPhysically, the condition of nutrition suffers profoundly, and there is a great loss of weight, because of the

nates.

small

amount

of food ingested

and great

restlessness.

The

temperature may be subnormal. A few cases of the agitated form

may

be characterized as

310

FORMS OF MENTAL DISEASE

These cases present an extreme grade of galloping paresis. excitement and profound clouding of consciousness, leading within a few weeks or months to fatal collapse. It sometimes
represents the end stage of the agitated form and occaThe patients are comsionally also of the depressed form. unable to comprehend the surroundings pletely confused, or to respond to questions.
singing,

They

are noisy, shouting

and

producing an
is

unintelligible babble, with

many
The

repetitions of syllables or purely inarticulate sounds.
restlessness

extreme, the patients being in constant motion, the bed or wall, forcing the legs up and down, pounding running about the room, slapping their hands, waltzing to

and bruising themselves extensively by their reckless movements. Insomnia is extreme and food is refused, or if taken, cannot be retained, and the patients are wholly unable to care for their personal needs. The weight falls rapidly, the temperature becomes slightly elevated, and the heart's action feeble and irregular. Epileptiform and attacks are frequent. Within a few days or apoplectiform
fro,

and

in

weeks the restlessness subsides into a condition of stupor, which the movements are uncertain and tremulous. The

temperature becomes elevated as the result of infection from the various wounds or acute decubitus, the mouth is filled
with sordes;
profuse perspiration

and diarrhoea appear,

which with heart failure lead to death. The agitated form represents about eleven per cent, of the Remissions occur in one-fourth of the cases. paretics.
Paralytic

attacks are

frequent.

The duration

in

more

than two-thirds of the cases

is less

than two years.

DEPRESSED FORM
This form is characterized by despondency and depressive delusions which prevail throughout the whole course of the disease.

DEMENTIA PARALYTICA
The
their
onset in this
failing

311
patients notice

form

is

insidious.

The

memory, decreasing power of application, weariness upon exertion, and change of disposition. greater The persistent headaches, the numerous pains, and failing

memory

lead

them

to consult one physician after another.

They worry about themselves and soon become hypochondriacal. They claim that they are suffering from a complication of diseases and that they can never recover. During
this stage they are not infrequently regarded as neuras-

theniacs, hypochondriacs, or hysterical patients. But their hypochondriacal complaints sooner or later be-

come
is

entirely senseless.

They then complain that the
is filled

scalp

rotting away, the skull is brain to shrink, the mouth
is lost,

filling in with bone, causing the

with

sores, the sense of

taste

the throat

is

clogged up, so that the food passes
is melted away, and the excrement has been accu-

up

into the brain, the

stomach

intestines are so paralyzed that

mulating within them for many months, the kidneys have been moved, so that water passes directly through their bodies. They claim that they are dead, the blood has
ceased to circulate, and they have turned to stone. The have dried up and their manhood has disappeared ; " " a false passage has formed so that the vital fluid passes
testicles

out of the rectum.

In connection with these ideas they are

constantly fingering different parts of the body, especially the face and sexual organs. They may sit for hours with hands on their throat for fear feces will pass into the mouth,
or

may

apart if Delusions of self-accusation are usually associated with
these hypochondriacal ideas
in the
clinical

abed as moved.
lie

if

dead, claiming that they would

fall

picture.

and occasionally predominate The patients believe themselves

great sinners, that they have committed the unpardonable

312
sin,

FORMS OF MENTAL DISEASE
must
die

have stolen property, and injured their children. They have caused the death of a friend by and every one knows that they are murderers. negligence, They persist that they have always been impure and have

on the

cross,

months because he had not provided his family with sufficient food and was being held up to the whole world as an example and must
led

many

astray.

A patient

moaned

for

Very often fear develops in connection with these ideas of self-accusation, when the patients are in terror because they are being constantly
watched, expecting at any moment to be imprisoned or carried away to the scaffold; or they dread personal injury

suffer the penalty of death.

and abuse.
Delusions of persecution are usually accompanied by halsuspect plots against their lives and complain that their families, are being outraged. They are being regarded as desperadoes on whose head there
is

lucinations of hearing,

when they

a high price.
into exile.
of

them
crowd

The troops have been summoned to escort They hear themselves slandered by a
Hallucinations of the other senses

men

outside, or overhear intrigues against them.

Others threaten them.

are infrequent. The consciousness soon becomes

much

clouded.

There

is

is

considerable disorientation; friends are mistaken, and time confused. Occurrences in the surroundings have reference

only to themselves. The bathing of others suggests to their minds that they have polluted their fellow-patients, and the
preparation for the morning walk signifies that the whole company are getting ready to attend their public prosecution. At the table others are deprived of food on their

In this condition they develop great anxiety with restlessness; pace back and forth in their rooms, moaning
account.

and groaning, sometimes uttering

single

expressions,

as

DEMENTIA PARALYTICA
"
death,"
their hair,

313

"

destruction," pick at their finger-nails, pull out

Finally they cannot be persuaded huddled up at one side, with the head buried in the clothing. In this condition they may
to leave the bed, but
lie

frightens farther into their rooms.

and are unable to eat. Every unusual sound them and causes them to shudder and shrink back

attempt suicide or mutilate their own bodies; one patient tore through the anal sphincter into the vagina with her hand.

Extreme anxiety with

restlessness does not exist very

long at a time, usually only for a few hours or at most a few weeks. It may appear and disappear suddenly. In

the interval the patients are not as agitated but yet are despondent and seclusive. The depressive delusions are retained but they show far less emotion. The mental depression is not always uniform, as one occasionally notices emotional indifference, and even transitory periods with a
feeling of well-being
is

and

of elation.

When

deterioration

well advanced, expansive delusions occasionally appear. More or less prolonged stuporous states appear at times

when the patients become abed in one position oblivious to the surroundmute, lying ings, refusing nourishment, and allowing the feces and urine
during the course of the disease,
to pass unheeded.

ignored.

Requests are carried out slowly or wholly The patients appear indifferent, but at times they

display some emotion, or they may show some anxiety. Hallucinations and illusions may be more or less prominent or entirely wanting. Consciousness is usually clouded.

These states

months. form of dementia paralytica comprises depressive one-fourth of the cases, and appears rather late in life,

may

last several

The

mostly after forty years of age. Remissions occur in less than twelve per cent, of the cases, while paralytic attacks

314

FORMS OF MENTAL DISEASE

occur in twenty-five percent. This type is one of the severer forms, as over seventy per cent, die within two
years.

Course of dementia paralytica. Dementia paralytica may be divided into three stages: the stage of onset, the stage of acute symptoms, and the terminal stage of dementia The lines
.

of division are very indefinite, as the first stage may very quickly

pass into the acute stage, when the symptoms remain in abeyance for a few years ; or the case may be one of apathetic deterioration from the onset, devoid of

indicative of definite stages.

any prominent symptoms The terminal stage is apt to

be prolonged.

the patients are dull, stupid, apathetic, entirely indifferent to their surroundings, unable to care for themselves, or occasionally expressing incoherent fragments
it

In

They sit unoccupied save for the taking which they often have to be helped. The physical symptoms in this stage advance to general paresis
of nourishment, to

of former delusions.

of all of the muscles, necessitating confinement in bed.

Sensation is greatly impaired, muscular atrophy and weakness become marked, and finally contractures appear. In the end patients become nothing more than vegetating
organisms.

The course

of the physical

symptoms by no

mental symptoms. On means the one hand, there are cases in which speech disturbances and incoordination may antedate for a long time the apcorrespond to those of the

pearance of faulty memory or judgment, and on the other hand, the mental symptoms may appear first.

The two important paralytic attacks and

factors in the course of the disease are

remissions.

The attacks may appear

at any time during the course, producing an unexpected progress in the deterioration or even a fatal termination.

They may usher
of

in the disease, being followed by a condition advanced deterioration, but more frequently occur during

DEMENTIA PARALYTICA

315

the terminal stage. These attacks accompany chiefly the demented and the expansive forms.

Remissions are most often encountered in the agitated and expansive forms and very rarely in the demented forms. The

improvement, which

is

earlier stages of the disease.

usually rapid, appears only during the Both the physical and mental

symptoms show marked improvement; the consciousness becomes clear, the content of thought coherent, and the delusions and hallucinations disappear. The patients often
look back upon their psychosis as a sort of dream, without In the course of a month or two they may clear insight. have improved so much that, as far as the limited associations

When of the institution permit, they appear perfectly well. at liberty, however, it is apparent to their friends that they
have
lost their

former mental energy; they

tire easily,

and
for

are changed in disposition.
exercise care.

Yet they are usually eager

employment and disregard the advice

of the physicians to

Some

of the patients are able to engage

successfully in their former occupation and support their In other cases the remission is only partial; the families.

become clear and coherent, while the expansive and depressive delusions disappear; but there still remains
patients

a tendency to excessive activity, with a desire to enter into uncertain business ventures, to be lavish with money, carepersonal appearance, and irritable and fretful in disThe duration of the remission seldom lasts over position.
less in

three or four months, but in

some

cases

it

extends over three
paresis, there

or

more

years.

Diagnosis.

During the early stages of

may

be considerable

difficulty in distinguishing acquired neuras-

thenia (see p. 153).

The

cholia of involution

depressive form of paresis is distinguished from melanby the evidences of mental deterioration:

316

FORMS OF MENTAL DISEASE

weakness of judgment, moral instability, failure of memory, defective time orientation, silliness and incoherence of the

and presence of physical signs. The melancholiac a greater prominence of self-accusations and good shows orientation, except in cases with many hallucinations and
delusions,

delusions.

The

intense apprehensiveness of the paretic

is

than that encountered in melancholia, and is relieved by short periods of moderate but occasionally distinct feeling of well-being. The melancholiacs have their good days, but they never show elation.
less persistent

depressive phases of manic-depressive insanity are distinguished by the absence of any signs of mental deteriora-

The

and by the presence of retardation among the motor phenomena. In the stuporous states the manic-depressive patient takes some notice of and partially apprehends his surroundings, although he takes no part in them; he shows some anxiety and discomfort when threatened with a needle and seldom moves voluntarily and then slowly, while the
tion
is partially disoriented, does not react when threatened with a needle, and occasionally moves freely and even

paretic

and usually presents characteristic physical signs. The manic phases of manic-depressive insanity are differentiated from the expansive and agitated forms of paresis by the absence of mental deterioration. The paretic is unable to recall correctly recent events, and especially the date of their occurrence. His delusions are more extreme, his emotional attitude is fantastic, and contradictory; and dependent upon the surroundings and sugvariable, The manic, on the other gestions, and he is more pliable. is more alert and quick in apprehending when his hand, attention can be attracted; he shows an accurate memory;
restlessly,

his delusions are less often contradictory, are expressed with
less

assurance and more facetiousness;

and he

is

seldom

DEMENTIA PARALYTICA
contented and
is less

317

pliable.

In conditions of extreme exciteis

ment, the orientation and the coherence of thought disturbed in paresis.
It often

more

happens that periods of excitement at the onset of the disease are mistaken for delirium tremens, especially where early paretic symptoms have escaped notice in an
alcoholic (see p. 183).

by the absence of the characteristic physical signs, good orientation, and the presence of catatonic features (see p. 270). The sois

Dementia prcecox

usually differentiated

symptoms, if they occur in paresis, are aca greater disturbance of memory and greater companied by insensibility and cloudiness than what one encounters in
called catatonic

dementia praecox. In case these distinguishing features cannot be determined, on account of negativistic signs, then
one has to depend upon the presence or absence of physical
signs.

The presence

of simple difference of pupils, increased

reflexes,

moderate tremor, and, indeed, even attacks of dizziness and of an epileptiform nature, are not conclusive for
paresis.
If

helpless in simple figuring tests,

a patient with such symptoms is uncertain and is unable to orient himself

as regards time and to readily recall early experiences, and is easily influenced in action and feeling, provided it is not the

mechanical response to stimuli, then the condition is more indicative of paresis. The states of dementia in paresis lack the tendency to adornment, the mannerisms, the occasional
exacerbations, refusal of food.

and the

persistent stupor, negativism,

and

In the paretic excitement, there

may

occur

impulsive and stereotyped movements; but they are not accompanied by the irrelevant and incoherent speech of the catatonic, and furthermore, the excited paretic is not
oriented to the extent that the catatonic usually is. In the paranoid forms there is neither the paretic inability to com-

318

FORMS OF MENTAL DISEASE

prehend the surroundings nor the permanent feeling of wellbeing, hallucinations are much more frequent and expansive delusions develop more slowly, while the paretic does not show
the delusions of influence so

common in

paranoid dementia.

The late

cases of dementia prsecox, in which despondency may predominate, are distinguished by the susceptibility to ex-

ternal influences, such as

commands, and by the impulsive

restlessness or stupor with resistiveness.

diagnosis may spinal fluid.

rest

Ultimately the the examination of the cerebroupon
is

The

differentiation of paresis

apt to be most

difficult

in those diseases in

which there are extensive
(see p. 331),

cortical lesions,

particularly cerebral syphilis

arteriosclerotic

insanity (see p. 338),

and

senile dementia.

Senile dementia

may be recognized by the age at onset, the more prolonged course, comparative poverty of delusions, and absence of
characteristic

motor symptoms.

toms similar to those
paralytica.
focal
disk.

Cases of cerebral tumor occasionally present mental sympin the demented form of dementia

The

chief point of differentiation, in case
exist,
is

no

symptoms

the presence of the cupped optic

The prognosis of the disease is decidedly unPrognosis. favorable. Death occurs in the vast majority of cases within
two years; the length of life, however, varies in the different forms. A few cases survive five or six years. One case of eighteen years' duration has been reported. There are, however, some cases of so-called arrested paresis Undoubtedly not a few of these cases were never paresis at all, but rather
.

belonged to the group of organic psychoses characterized by
degenerative changes in the cortex, especially syphilitic, which during life are differentiated only with great difficulty. Again, there is a possibility that some of
extensive

DEMENTIA PARALYTICA

319

these cases represent a group of cases still undifferentiated, which at the onset present the characteristic mental and
physical symptoms of paresis, but later subside into a condition of dementia with possibly a few delusions and the
It cannot be positively residuals of the former physical signs stated that some of these are not paretic cases which fail to
.

run the usual

fatal course.

It is still

a mooted question

whether patients may not even recover from paresis. In the first place, Tuczek reports a genuine case of paresis, confirmed by autopsy, with a remission of twenty years. Again, Alzheimer has found in paretics, dying during a complete

When one remission, the characteristic paretic lesions. considers that these remissions often cannot be distinguished
from genuine
recoveries, except for the later recurrence of

the disease, it at once becomes apparent that a complete subsidence of all mental symptoms may occur, which, extending through a series of years, encourages the belief that
recoveries are possible. The immediate causes of death are paralytic attacks, pneumonia, and intercurrent diseases,

sometimes septicaemia following infection from wounds, sometimes suffocation caused by food entering the air passages; but the usual manner of death is from marasmus

and heart

failure. The patients become emaciated, the muscles atrophy, the heart weakens, the pulse becomes im-

perceptible,

and

life

gradually flickers out.
is

Treatment.
tomatic.

The treatment of the disease is mostly sympa history of probable

In cases where there

syphilitic infection the intensified mercurial treatment is 1 It consists justified by the small number of reported cures.

in the

intramuscular injection of mercuric salicylate in albolene, beginning with J grain twice weekly and increasing
1

Collins,

Med. Record, Vol.

9, p.

125.

Dana, Jour. Amer. Med. Ass'n,

May

6,

1905.

320

FORMS OF MENTAL DISEASE

to 1 J grains, administered for six weeks, and then an interval of six months during which general tonics are pushed.

Following this, another period of similar mercurial treatment. Some prefer the injection of bichloride of mercury,
J to J grain daily, given for six to eight weeks, repeated after an interval of six months. All other specific methods of

treatment have fallen into disuse.

utmost importance that the patient be submitted forced rest, with removal from business and uncomto fortable surroundings, and the establishment of a suitable
It is of

Quiet and daily routine in the physical and mental life. tractable patients in good circumstances may be treated at

home, but others usually require sanitarium or hospital treatment. Suitable rest and relaxation cannot be procured " " at the fashionable health resorts with the numerous cures

and attractions. Next to rest, there should be outlined a simple

nutritious

diet, including abstinence as regards alcohol, coffee, tea, and A carefully planned daily routine, including extobacco.

ercise in the

open

air,

and

carefully executed hydrotherapy

with gentle massage,

is

of importance.

The

conditions of paretic excitement are best relieved

by

the bed treatment and the use of the prolonged warm baths 1 At the first application of the bath, it may be (see p. 140).
is inaccessible, the cold packs may be substihands of several American physicians seem to give excellent results. The packs to be effective must be properly applied. The partial pack usually suffices to bring about the desired result, applying it to the lower extremities, or to the arms. In the whole pack a large and heavy woollen blanket is spread upon the mattress, and over it is laid a coarse linen sheet, well wrung out in water of a temperature from sixty to seventy degrees, so placed that the patient can lie at the junction of the middle, and right third of the sheet. When the patient is in position, with the arms elevated, and provided with a wet turban, the right portion of the sheet is drawn across the body and tucked. The arms are lowered
1

Where the warm bath
which
in the

tuted,

DEMENTIA PARALYTICA

321

necessary to give preliminary doses of hyoscine. If the excitement is extreme, forced feeding or hypodermoclysis with normal saline solution (see p. 139) given twice daily should be employed. The conditions of extreme anxious
restlessness

and agitation should
if

also be treated with the

prolonged

necessary the use of the hypodermoclysis, but not infrequently these patients fail to yield to any form of treatment, when all that remains to be done
is

warm bath and

to

watch the patient carefully to prevent
last stages of the disease,

injuries

and to
is

maintain nutrition.

In the

extreme cleanliness

most

in order to prevent bedsores. The bedmust be kept dry, clean, smooth, and free from clothing crumbs, and the body frequently cleansed with cold water. Alcohol or hardening applications are better withheld, and instead the skin should be carefully rubbed with cocoa
essential

butter.

Frequent changes of the position of the body every

hour, day of acute

and

night, aid greatly in preventing the occurrence

and hypostatic pneumonia. Acute decubitus, once formed, is very obstinate and should be treated surgically like an ulcer. Where there is a marked tendency to the formation of acute decubitus and also where it does not heal readily, the best method is to keep the
decubitus
and covered with the left portion of the sheet, which is drawn body and securely tucked, especially about the neck and feet. The patient is then covered with several woollen blankets. The duration of the pack should be from one-half to one hour, and may be followed by brisk rubbing with alcohol. The duration of the partial pack may be more extended than that of the whole pack. When the patient falls asleep in it, it is not necessary that it be removed until he awakes. There is no harm in an immediate renewal of the partial pack. It should be remembered in the application of these partial packs, as well as in the whole packs, that all air must be excluded from in under the cover of
to the side
across the

woollen blankets, for which purpose
cloth or oil silk.

many

use a final covering of rubber

322
patient

FORMS OF MENTAL DISEASE
continually
in

the prolonged warm bath. The nourishment during this stage must be liquid, in order to prevent choking. Daily percussion of the lower abdomen
to detect distention of the bladder

and observation

of the
is

condition of the bowels is also necessary.

In case there

paralysis of the bladder, the patient should be regularly catheterized, followed by a washing of the bladder with a

saturated solution of boracic acid.

Finally,

the

mouth

should be kept thoroughly clean. The paralytic attacks may yield to ice packs on the head or to amylene hydrate (thirty to sixty minims) or chloral hydrate, the former of

which may be given by subcutaneous injections in a five to ten per cent, solution. If immediate action is demanded,
chloroform

may

be employed.

VII.

ORGANIC DEMENTIAS

1

here used in a limited sense, applying only to those psychoses that are associated with organic disis

THE term

ease of the central nervous system,
gliosis,

and includes cerebral
sclerosis,

Huntingdon's chorea, multiple

cerebral

syphilis, tabetic psychoses, arteriosclerotic insanity, brain tumor, cerebral trauma, and cerebral apoplexy.

This disease, described by Fuerstner, presents numerous tumorlike accumulations of glia in the superficial layers of the cortex with the formation of small
Gliosis of Cortex.

cavities

and atrophy
of

of the nervous tissue.
is

The

course of the disease

toms may be
tability,

chronic, the mental sympsudden onset with convulsions and irri-

but later there develops a progressive deterioration

with failing memory, accompanied by disorder of speech, optic atrophy, and often tabetic symptoms. Diffuse cerebral sclerosis,

in

which there
tissue,
is

is

an extensive increase of

the

supportive dementia.

accompanied

by progressive

The mental symptons of HunHuntingdon's Chorea. tingdon's chorea are distinctive, consisting usually of a progressive dementia with faulty
paralysis
1

of

memory, weak judgment, Patients thought, apathy, and irritabihty.

Facklam, Archiv f. Psy., XXX, S. 138. Zinn, Archiv f. Psy., XXVIII, S. 411. Diller, Am. Jour. Med. Sciences, Dec., 1889, April, 1890. Hallock, Jour. Nerv. & Ment. Dis., 1898.
Sinkler,

Med. Rec., XLI,

p. 281.

324

FORMS OF MENTAL DISEASE

are unstable in employment. Suicidal attempts are not infrequent, and occasional homicidal tendencies are encountered.
if

Hallucinations

present are unaccompanied by emotion.

and delusions are infrequent, but Anxious states,

outbreaks of anger, restlessness, sometimes develop. The choreic movements are intensified by any mental excitement.
Physically

the

choreic

movements

of

Huntingdon's

chorea differ from those of acute chorea in that they are less extensive and less frequent. They involve the entire
trunk, limb, head and face, and are jerky, at times quick, but often sluggish. The speech becomes hesitating, indistinct,

and

indecisive, while the writing

The voluntary movements

is rapid and hasty. are rendered uncertain, yet it

is surprising to observe how advanced cases maintain their equilibrium in walking. The arms, head, and trunk may be drawn into various awkward positions, the

patient

still

keeping

on

his

feet.

The

accompanying

photographic group (Plate 9), of three cases of Huntingdon's chorea, shows the rapidly changing attitudes of these

As patients who were trying to look at the photographer. muscular strength wanes, the disease advances, general until in the end stages the patients become bedridden. The deep tendon
muscle
reflexes are usually exaggerated,

and the

irritability

increased.

Sensation does not suffer.

Epileptiform and apoplectic attacks rarely occur.
course of Huntingdon's chorea is slowly progressive, leading in the greater number of cases to considerable

The

dementia in the course of ten to thirty years. The mental symptoms usually appear coincidently with the first of the
choreiform movements, but they may not appear for years ; indeed, the writer knows of one case of Huntingdon's chorea
of fifteen years' standing in which the individual still conducts While the successfully a large and lucrative law practice.

ORGANIC DEMENTIAS

325

underlying mental process is one of progressive dementia, as described above, the onset of the mental symptoms may be sudden and of a manic character; occasionally
the

symptoms simulate the megalomanic phase

of paresis

;

again the clinical picture
character,

may

be distinctly depressive in

accompanied by active hallucinosis and delusion These various clinical states, however, are formation.
usually

only

episodic,

while

deterioration

progresses.

Marked dementia may have already become evident before
these various episodes appear. Furthermore, there is no relationship between the degree of choreic movements and

mental symptoms either group may be much more Sometimes the or much less advanced than the other.
the
:

choreic

movements improve considerably during the course

of the disease.

Where the mental symptoms antedate or predominate in the clinical picture, there may be some In such cases one must difficulty in differentiating paresis.
Diagnosis.

depend upon the absence

of pupillary disturbances or musthe presence of only a hesitancy in speech cular paresis, with hastiness and tremor in writing, without defect in the

content of speech and writing. In the mental field the emotional irritability is more disturbed, and there is proportionately less defect of memory and orientation. The history of Huntingdon's chorea in the antecedents should
leave
little

doubt as to the true character of the

disease.

The pathological anatomy of Huntingdon's chorea presents chronic leptomeningitis, with thickening of the pia and small cell infiltration, general cerebral atrophy with
shrinking of the cortex, white matter, and basal ganglia. The vessels exhibit extensive thickening of the adventitia

with increase in the perivascular spaces, and in places residIn four of the writer's cases, cell uals of old hemorrhages.

326

FORMS OF MENTAL DISEASE

shrinkage was observed, and in one case also grave alter-

Trabantan cells were present in most sections, while glia nuclei were uniformly increased in the deeper In all, vascular alteration was preslayers of the cortex. ent, with round cell infiltration, as well as the presence In one case there was of free pigment about the vessels. a slight degree of ependymitis, and in another, numerous areas of thrombotic softening were found scattered over the
ation.

cortex.

Multiple Sclerosis. ple sclerosis involves
less

the disease process in multithe brain, there develops more or

When

In 215 cases reported by Berger in 1904, dementia occurred in only 24 cases (more than 10 per The type of mental disturbance is usually that of cent).

mental deterioration.

simple deterioration with failure of memory and judgment, together with apathy, as seen in an unnatural complacency and anergy. Besides the emotional apathy, there is some-

times present a tendency to uncontrollable laughter, and other emotional outbursts of an episodic character. The

mental symptoms, however, are rarely of such pronounced
character as to

An

bring the patient to insane hospitals. case of multiple sclerosis may be confounded atypical

with

dementia

paralytica,

particularly

if

nystagmus,

scanning speech, and intention tremor are tardy in appearance or absent. The burden of proof against dementia
paralytica then rests

upon the absence

of pupillary dis-

turbance, and of the characteristic paretic speech; while in the mental field there is absence of faulty time orientation and prominent defect of memory.
Cerebral Syphilis.

In cerebral syphilis there are two

groups of cases: simple syphilitic dementia,

and

syphilitic

term are not included the pseudoparesis. mental disturbances occurring during the early mani-

Under

this

ORGANIC DEMENTIAS
festations,

327

such as the occasional deliria similar in nature

to infectious deliria, or the hysterical and neurasthenic syndromes, in all of which syphilis seems to play the role only of an exciting factor. The distinctively characteristic
syphilitic psychoses develop

when
The

there

is

only during the late period, involvement of the cerebral vessels and the

development of gummata, vascular occlusion, and malacia.
vessel alteration is typically syphilitic and gives rise to a profound nutritional disturbance in the cortex. It is

from that occurring in paresis by the is only very slight infiltration into the adventitia of the vessels, and mast cells are rare but there is a marked proliferation of the intimal cells,
to be differentiated

pathological fact that there

;

with a tendency to
vessel
typical.
itself.

form vascular foramina
vessel formation
is

within the

The new

extensive and

The

elastic fibres of

the vessels tend to split into

layers, while the vascular cells do not show pigmentation. In simple syphilitic dementia there usually appears first, defective memory and judgment, and some absent-minded-

ness, as well as lack of insight into these defects.

Coin-

cident with the onset there usually occurs

some

sort of

an

apoplectiform seizure, which

may

be either of a mild or

a severe grade.
tion.

The

Emotionally there is a slight degree of elapatients are fond of boasting of their strength

and plan extensively for the future. If there to be present some feeling of illness, they are happens confident of recovery. But more prominent still is the

and

ability,

greatly increased emotional irritability, which often leads to strife and outbursts of passion. Delusions of influence

and reference are sometimes present, also ideas of oppression and mistreatment, to which are ascribed sordid motives;

but such delusional ideas are transient and rarely elaborated. Volitionally there is evident weakness of will,

328
as

FORMS OF MENTAL DISEASE
in their tractability

shown

and

fickleness.

They tend

to

be thoughtless, disorderly in their work, neglect important for unimportant matters, and do all sorts of extravagant
things.

Finally, there

is

a striking susceptibility to alcohol.

The course of the disease is usually slow, although it may soon reach a stage of quiescence, with subsidence of the
prominent symptoms. Recovery is rare, in spite of antisyphilitic treatment, because the cortex has become extensively

involved.

There are occasional exacerbations.

Physically, the onset is usually with an apoplectiform attack J and as the result of this there may be residual hemiplegia

or monoplegia, sometimes paresis of the eye muscles, some slight fault of articulation, and also complete or reflex
iridoplegia.

This group of cases should also include that form of
progressive deterioration appearing in youth which arises

from congenital syphilis and
of paralysis.

accompanied by forms The pathological distinction between these
is

cases

and juvenile

paresis

is

that in the former there exists

only the vascular lesions characteristic of syphilis. However, Meyer and Kaplan have described some cases in which
there was a mixture of paretic and syphilitic lesions. To this group also should be added the cases described
Barrett, Bechterew, and Jurgens, in which the lesion one of disseminated syphilitic encephalitis.

by

1

2

3

is

In Barrett's case the deterioration was very rapid, leading
to complete dementia and death within two months, while in the case of Bechterew the course of the disease extended

through two years.
1

Amer. Jour, of Med.

Sc., Vol. 129, p. 390.

3

Handbuch der
Minor.

path. Anat. des Nervensystems.

Flatan-Jacobsohn-

*

Ref. Oppenheim, Syphilitische Erkrank des Gehirns.

ORGANIC DEMENTIAS

329

Syphilitic pseudoparesis includes those cases of cerebral

syphilis

which present pronounced mental symptoms, in addition to the evidences of focal brain lesions. The gradations
sis

between simple

syphilitic

dementia and pseudoparecases that

are so imperceptible in

many

some authors

do not attempt a differentiation, but describe both groups under cerebral syphilis. The onset of pseudoparesis, as in

The

simple syphilitic dementia, may be with paralytic attacks. attacks may be only syncopal, or aphasiform and of short duration, or there may be loss of consciousness with

more or less severe paralysis. Such attacks may antedate many months the mental symptoms, or they may be tardy in appearing and sometimes they never develop. Of the
mental symptoms, despondency is the first to appear, in which either hypochondriasis or apprehensiveness predominate. The patients feel stupid, the food does not agree
with them,
of infidelity. There

they are self-accusatory, fearful, and speak is a change of character, and they become
thought; at other times

indifferent, forgetful, confused in

they are irritable, excitable, and aggressive. Even delirious Hallucinations are usually excitement may develop. and often very prominent, mostly of hearing, present

though sometimes of sight and smell. The megalomanic delusions so characteristic of paresis predominate and with this there is emotional elation and a tendency to facetiousness, although

some patients are

irritable, suspicious,

and and

hostile.

Many

patients are productive both in speech

writing, exhibiting incoherence

others are inactive, sleepy, vary from one state to another.
residuals of syphilitic infection,

and even neologisms ; and reticent, and again others
Physically
,

besides the

and form attacks, such as hemiparesis, hemianopsia, and paraphasia, etc., there may be present optic atrophy, an increase,

of the earlier apoplecti-

330

FORMS OF MENTAL DISEASE

absence or weakening, and particularly inequality of the tendon reflexes, and complete or almost complete loss of the light reaction of one or both pupils. Speech and writing,

however, show insignificant changes. The course of the disease is slow, leading regularly to a considerable degree of dementia. Some patients continue
orderly and are able to live at
ability to read

home; they possess the and amuse themselves, and follow up a simple

daily routine, but are wholly incapable of profitable employment, lack insight into their condition, and are thoughtless of the future. They continue oriented, but memory for

events of the psychosis and sometimes even for earlier life is faulty. The hallucinations and delusions tend to reap-

pear; these are never modified but only forgotten. In the severer cases the dementia is more profound;

the patients are continuously confused, maintaining their various expansive and persecutory delusions, exhibiting

and aggressiveness, or they may be childishly good-natured and thoroughly tractable. Transitory conditions of profound stupidity and confusion arise.
restlessness, excitement,

Paralytic attacks, either epileptiform or syncopal, with or without residuals, reappear with more or less regularity

throughout the course and

The

course of the

may symptoms may

terminate the disease.

not be as progressive,

but after reaching a certain stage remain unchanged a long time, until an exacerbation or some intercurrent disease causes death.

pathology of pseudoparesis exhibits the following syphilitic lesions: meningitis, foci of malacia, gummata,

The

and particularly the

syphilitic vascular lesions.
is

Through-

out the entire cortex there

a hyperplasia of glia cells, so much so that in places the "gliarasen" of Nissl is found, indicating a profound degeneration of nerve cells.

ORGANIC DEMENTIAS

331

much involved, and there of glia fibres, and hence development very Regressive changes practically no reduction of the cortex.
The nerve
is

fibres,

however, are not

also

little

neuroglia cells. In the deeper layers of the cortex there is a large increase of small round glia

may

be seen in

many

nuclei.

The

large vessels are deeply stained (Nissl's stain)

and the perivascular spaces are enlarged, although there is no infiltration of the adventitia similar to what one finds
in dementia paralytica. The small vessels are greatly increased in number, dilated, and present many anastamoses,

appearing

everywhere

to

be

overlaid

with

glia

cells.

According to

Nissl, this proliferation does not take place by as in paresis, but by the formation of new vessel budding

openings through the thickened endothelium among the numerous layers of the elastic coat. The muscular coat
Finally, rod cells are very rarely found. These extend throughout the cortex, but to a varying degree, in places being almost imperceptible. They are always more marked in the superficial layers of the cortex. Occa-

disappears.
lesions

sionally small old or fresh hemorrhagic foci are found. The similarity of pseudoparesis to general paresis
striking that the differential diagnosis
is

is

so

very

difficult

and

depends mostly upon the presence and persistence of the residuals of the paralytic attacks. These often exist from
the onset, which
is

paretic faults of speech

not true in paresis. The characteristic and writing, with the aphasia and

stumbling over syllables, the transposition and the repetition of syllables and letters, are absent, as well as the disturbances of the sensibility to pain. Memory is better than in paresis, and except in the very bad cases, orientation is preserved, i.e. names of persons are recalled and the patients

remember striking and also take some pride

incidents in their environment,
in neatness

and

order.

At the

332
onset,

FORMS OF MENTAL DISEASE
when
differentiation
is

most

difficult,

one observes

that in paresis the memory defect is out of proportion to the disorder in the rest of the mental life, and hallucinations
are less prominent than in pseudoparesis.

The

treatment of

pseudoparesis presents but little hope, although the few favorable cases following antisyphilitic treatment warrant a
trial in all (see p. 319).

In most cases where mental symptoms develop during the course of tabes, the disease terminates as paresis, but there are a few cases which never
Tabetic Psychoses.

become

paretic.

Very mild mental symptoms often appear

during the early stages of tabes, i.e. some fault of memory, and an increased sense of fatigue, but more especially a

change in disposition.
hopeless,
cheerful,

Many

patients

become gloomy and

and have forebodings and fears, but others are happy, and confident, sometimes reminding one
is

of the feeling of well-being of the paretic.

The

characteristic tabetic psychosis, however,

an acute

hallucinosis with

some excitement resembling the acute The onset of the hallucinosis is sudden, with hallucinations of hearing, accompanied by some anxiety and restlessness. Later hallucinations of the other senses appear. The hallucinations are of a threatenalcoholic hallucinosis.

such as the voices of relatives calling for help, threats against their lives, the odor of sulphur, or the sensation of electricity, to all of which the patients
ing, disturbing

type

:

react.

Orientation remains clear.

attack

may be

for a

few weeks or

The duration of the several months, when the
There

symptoms
sions.

often disappear suddenly.

may be

remis-

psychosis may resemble a short hallucinatory delirium, or it may simulate a chronic psychosis with hallucinations and paranoid delusions, both of persecution

The

ORGANIC DEMENTIAS
and grandeur.
cess, similar to

333

Again

all

of these different

forms

may

represent different clinical stages of

the same disease pro-

the acute and chronic disease pictures which

one sees in

paresis, alcoholism,

and dementia
is

prsecox.

In

some

of the chronic cases there

a similarity to syphilitic

pseudoparesis. Besides these forms of tabetic psychoses there may develop in tabes the manic-depressive syndrome,

the catatonic orthe senile psychoses. The tabetic psychoses are differentiated from the forms of paresis by the fact that
the disease process
is

not progressive.

The grade

of dete-

rioration remains at a standstill,

and memory
paresis.

is

and furthermore, attention not disturbed to the degree that it is in
1

Arteriosclerotic

Insanity.

Arteriosclerotic

changes

in

the brain are very common life, yet it is doubtful if one is justified in considering them only as evidence of early senility, particularly in view of the fact
in the senile period of

that extensive

arteriosclerosis

may

exist

without accomeither
is

panying mental impairment.
that

One must conclude

the vascular

disease, in arteriosclerotic

insanity

not, in spite its great similarity, identical with that occurring in normal senility, or that in the former case the vas-

cular change is an accompaniment of only secondary importance in a disease process which is highly destructive of

nerve tissue.
especially

The varying extent
it

of the vessel change,

whether

involves the smaller or greater vessels,

may

account for the absence or presence of mental mani-

festations.

1

Alzheimer, Allgem. Zeitschr. LIX, 695.

f.

Psy., LI, 809;

idem, LIII, 863; idem,

Alzheimer,

Binswanger, Berl. Klin. Wochenschr, 1894, 49. Histologische und Histopathologische
Grosshirurinde-Nissl, Jena, 1904.

Arbeiten liber die

334

FORMS OF MENTAL DISEASE

cases

This psychosis appears about the sixtieth year; yet some develop before fifty, but in the latter instance

there

is usually present a strong hereditary tendency to vascular disease. Alcoholism and syphilis may be regarded

as etiological factors.
life,

the arteriosclerosis

When the disease occurs later in may be associated with the charac-

changes of the nervous tissue which are dependent upon the vascular changes. Alzheimer speaks " This form of disease Senile Decay." of these cases as
teristic senile

attacks especially the cortical vessels that pass in from the pia, leading to the formation of deep wedge-shaped foci with destruction of the nerve tissue and an increase
of glia.

There is regularly found, besides Pathological Anatomy. the evidences of general arteriosclerosis, cardiac involvement, either cardiac hypertrophy or dilation, and interstitial nephritis.

The

cerebral vessels are thickened

and

rigid,

and the

the dura and pia thickened, the latter being cloudy, Several entire brain is more or less atrophied.

areas of hemorrhagic softening, either fresh or old, are usually found in the cortex, and the ventricles are much dilated.

the numerous disease foci are found, the path of the altered vessels. In these especially along areas the nervous tissue has disappeared, being replaced by a luxuriant growth of neuroglia, which shows little or no
Microscopically,

tendency to regressive changes.
addition to

The blood

vessels,

in

namely, a splitting and swelling of the elastica, thickening of the walls, and regressive changes in the muscularis and adventitia, also

the

usual

arteriosclerotic changes,

show a tendency
is

lymph

spaces there

In the to hyaline infiltration. increase of connective tissue, pig-

mentation, and granular cells. Comparing the normal with the arteriosclerotic cortex, as seen inFigures 1 and 2, Plate 10
5

.X'.V^
* *

*

.''

v '.":"
*

..*'*"**

*VV'*'

V*r^W

>:

^-

">

PLATE
Fig. 1

10
Fig. 2

Arteriosclerotic cortex.

Normal

cortex.

ORGANIC DEMENTIAS
it is

335

apparent how extensive the degeneration of cells has been. The few remaining nerve cells present a high-grade

Deeply stained glia nuclei are scattered everywhere, mostly surrounded by a clear space, and gathered in groups, particularly about The vessels themselves, both large and small, vessels. few nuclei, are hyaline and greatly thickened. Some present vessels appear to have a double lumen, which is very frequently found in the arteriosclerotic cortex. The disease process is not evenly distributed throughout the entire
cortex, as there are foci

alteration in the intercellular tissue.

noted.

where only moderate changes are one cannot judge of the extent of the Further,

vascular change in the cortical vessels by the appearance of the larger vessels in the pia, as the latter may be much
altered, while the

former show

little

change.

The nerve

fibres, both in the cortex and in the white matter, show changes proportionate to the vascular disease. There

usually are numerous cavities in the white matter, particularly along the line of the vessels. This condition, called

crMe, presents a very characteristic picture. Where this state is very pronounced and where the subcortical region is more involved than the cortex, it has been called,
etat

by Binswanger, chronic

subcortical

encephalitis.

Clini-

cally these cases are characterized by very many limited The focal symptoms and a very pronounced dementia.

pyramidal tracts

may show atrophy in the pons and medulla.
The first symptoms
of arteriosclerotic

Symptomatology.

insanity consist of a diminution of energy, and forgetfulness. The patients tire easily, lack the characteristic fresh-

and energy for work. They not only hesitate to undertake anything new, but lack ability to do original work. Emotionally, they are easily depressed, disheartened,
ness
at times whining
;

again, they

may be

irritable,

and sub-

336
ject to

FORMS OP MENTAL DISEASE

emotional outbursts. Emotional instability is apt to be present, as seen in rapid changes from one emotional state to another and in frequent weeping and laughing. Patients are forgetful and flighty, and mix up their work.

There
that

always present a very definite feeling of illness may even border on hypochondriasis. This may lead
is

to suicidal attempts.

Under the

influence of alcohol or

some emotional
develop. reference

a moderate degree of dazedness may in the course of the disease delusions of Later
stress

and particularly

of infidelity are prone to appear.

physical symptoms are more or less pronounced attacks of dizziness, syncope, or even convulsive attacks, which may be accompanied by paraphasic disturb-

The prominent

ances, disturbances of sensation, paresis,

and even
persist.

paralysis.

Residuals
reaction
is

of

these

attacks

usually
is

Pupillary

retained, or at

most
is

only slightly sluggish.

The usual vascular and
sclerosis are present,

cardiac

and there

symptoms of arterioalbumen in the urine.
standstill for years,
is

These symptoms
particularly
if

may

remain at a

the patient's method of living

carefully

regulated, but sooner or later apoplexy appears with its With each recurring attack there is further deresiduals.

mentia, in which attention and memory suffer. Later there develops complete disorientation, and indifference,

but at times there

is

childish irritability

and at others

happiness. Finally deterioration becomes so pronounced that they have to be cared for and fed like little children.

Not

all

there

cases develop this degree of deterioration; indeed, may be all grades of dementia. Aphasia, agraphia,

apraxia, and asymbolism, also word and mind blindness, are frequent complications of these vascular lesions, which

tend to

make

than

it

the mental deterioration appear even greater really is. There are old apoplectics of ten years'

ORGANIC DEMENTIAS
or

337

more duration who present only an increased sense of mental fatigue, ill-humor, and some weakness of will,
rendering them particularly susceptible to outside influences. In such cases the vascular lesions are supposed to be more

circumscribed or to have come to a standstill.

a group of cases of arteriosclerotic insanity that deserve special attention; namely, those comprising the

There

is

severe

progressive

form.

These

cases

are

characterized

by a very rapid course leading to profound dementia and death. The disease usually begins with an apoplectiform attack, although there may have been prodromal headaches,
some
forgetfulness,

and lack

of

energy.

Following this

there develops a condition of
hensiveness,

marked anxiety and appre-

sometimes with pronounced delusions of a

persecutory nature, occasionally hallucinations and delusions of self -accusation. The patients are usually clouded and that they do not even understand what goes on about them or what is said to them. They are
confused, so
irritable,
restless,

much so

aggressive,

wandering about, attempt

escape, trying to jump from the window, or commit suicide. Nocturnal restlessness is particularly marked. Nutrition

and

There regularly develop for longer or shorter periods conditions of even greater bewilderment and more active restlessness. The patients become even more clouded, so that they perceive practically nothing and their attention cannot be fixed. Obstacles placed before them are not perceived or are handled in a
sleep suffer profoundly.

wholly automatic manner. They will not avoid a test needle, although they wince from pain. Emotionally, they manifest lack of feeling, although occasionally there may be

some anxiety or again some elation. Insight is absent. The patients present an almost incessant, motiveless The speech activity, and they have no care of themselves.

338
is

FORMS OF MENTAL DISEASE
and often

usually wholly incoherent, sort of babbling,

Such mental states usually end in death. Yet the excitement may disappear, leaving the patient in a condition of dementia which then becomes gradually
unintelligible.

progressive.

The

patients are wholly

listless,

disoriented,

and comprehend only the simplest questions. They have neither the energy to busy themselves nor the interest to mingle much in their environment. There is great emotional weakness and the patients laugh and cry very easily; even spasmodic laughing and crying may exist. In spite of
their great deterioration, they

may

be able to solve simple

mathematical problems, and not only recognize the members of their family, but derive some enjoyment from their visits. Physically, in addition to the residuals of the apoplectic

which paraphasic disturbances are apt to be is also a peculiar impediment of speech which may sometimes lead to genuine scanning. The
attacks, in

prominent, there

writing also presents marked changes. Individual letters are barely legible, even though ataxia is not evident. The
patients lose their ability to write the single strokes into a complete word. In the words that can be read omissions

These faults of writing are present from the beginning and may be regarded as a sign of rapid fatigue. The pupillary reaction is always maintained, although someare found.

times

it is

sluggish.

The

entire duration of the disease is

about four years, though there are cases of six to seven years' duration ; and again, some cases run a course of only
a few months.
fluenced

The prognosis in any case is always inthe general physical condition, especially the by condition of the heart, lungs, and kidneys, as well as the The

age of the patient.
diagnosis of arteriosclerotic insanity may be difficult, particularly the differentiation from paresis occurring in

ORGANIC DEMENTIAS
late
life.

339

place, it must be remembered that lesion of the cortex, while in arterioparesis is a diffuse

In the

first

sclerotic insanity there are

many

scattered foci.

Therefore,

we

find in paresis that the general psychic alteration is

more prominent than the physical signs. Paretics are usually clouded and exhibit loss of judgment before the
in arteriosclerotic insanphysical symptoms appear, while the apoplectiform attacks are very often the startingity

the psychical disturbances. In arteriosclerotic insanity disturbances of perception are more striking than disturbances of memory, while in paresis both are equally impaired. Emotionally, the paretic shows greater elation
point of
or depression ; while the arteriosclerotic patient is usually indifferent and apathetic, or he presents either hypochongreat elation of some paretics and the profusion of delusions is wholly lacking in the arteriosclerotic condition. Fabrication, aldriacal

despondency or indefinite

fear.

The

though a prominent symptom in paresis,
in

is

seldom indulged
it is

by the arteriosclerotic patient, and then

of

an

altogether different character, being meagre and without the florid embellishments of the paretic fabrication. These
patients also present in a marked degree lack of mental power ; yet at times they suddenly surprise one with their knowledge, although at other times they appear much de-

There does not appear to be such a complete loss of mental power as in paresis, but an inability to control it, and corresponding to this there is a greatly increased sense
mented.
of fatigue

not present in paresis. Finally, in spite of the apparent great dementia, many of the arteriosclerotic patients remain oriented to the end, recognize their relatives
is

which

and enjoy their visits, having good insight into their physical and mental helplessness. Further, physically there is a marked contrast between

340

FORMS OF MENTAL DISEASE

the paretic and arteriosclerotic symptoms. In the arteriosclerotic state the physical symptoms are prominent ;

such as persistent, well-defined paralyses
contractures, aphasia, asymbolism,

with spasms,

word blindness, mind and astereognosis. The speech blindness, hemianopsia, disturbance is more of the type that arises from paralysis, while in writing, simple omissions are more prominent than the ataxia and the transposition of syllables seen in paresis. The pupils remain Very often perseveration is present.
normal.
in the

The presence

of arteriosclerotic changes elsewhere

body point to a similar condition in the brain, but the former is no sure criterion of the extent of the brain
involvement.

In the

earliest stages of the disease,

when the

diagnosis may difficult, the predominance of the general physical symptoms over the mental symptoms, the latter of which are more apparent to the patient himself

be most

than to the

friends,

always favors a diagnosis of arteriodementia

sclerotic insanity.

Simple

syphilitic

may
with

be differentiated from

arteriosclerotic insanity only

difficulty, particularly in the early stages. In the syphilitic psychosis, we perceive a slower development of the 'symptoms, and the dis-

turbances of

memory and

while the focal

symptoms and variable than in the arteriosclerotic condition; again,

perception are less pronounced, are more uniform, less manifold

the tendency to oculomotor disturbance, of optic disorder, and paralysis of the pupils is of importance as well as the

knowledge of syphilitic disease elsewhere in the body. In differentiating pseudoparesis we find that the course is
not as progressive as in arteriosclerotic insanity, while the hallucinations and delusions are not nearly as promi-

nent

and are often absent

in

arteriosclerotic

insanity.

The degree

of deterioration does not

become as great;

ORGANIC DEMENTIAS

341

memory
The
of
all,

is

better, orientation is retained,

and the patients

continue conscious.
treatment of arteriosclerotic insanity demands, first rest, freedom from occupation, avoidance of exciteall articles of diet

ment and

that interfere with the vascular
coffee, tea,

system; namely, alcohol,

and much tobacco.
be avoided, as

Forms

of excessive exercise should also

It is doubtful if swimming, rowing, bicycle riding, etc. the administration of potassium iodide or the employment of foods containing calcium have any beneficial effect.

In the later stages of the disease the patients are apt to

become bedridden, and require very careful nursing. Cerebral Tumor. In cerebral tumor all cases do not develop mental symptoms. Of 318 cases Gianelli discovered
but 299 that developed a psychosis.
If

the cortex

is

not

much

involved or

if

the tumor

is

of slow growth, mental

symptoms may not appear.
develop where there
in such cases there
is is

On the other hand, they may a small circumscribed growth, but always the possibility of chemical

or other destructive agencies extending over a broader If the growth is of considerable size, mental symparea.

toms are sure to appear.

According to Schusters, tumors of the hypophysis in about two-thirds of the cases develop a psychosis, of the cerebellum in one-third of the cases, and

stem in one-fourth of the cases. In these cases the influence upon the cortex may arise from increase of the general pressure and interference with the blood supply, both venous and arterial. In tumors
of the of the corpus callosum the destruction of the association

beween the two hemispheres has some effect upon the mentality. In general, then, the effect of tumors outside the cortex upon the mental processes depends upon their size. This theory receives some support from the fact that extenfibres

342

FORMS OF MENTAL DISEASE

sive tumors, involving even the cortex,

may run their

course

without mental symptoms, if the tissue is gradually destroyed,

and not put under pressure ; while, on the other hand, even small tumors of the brain are often observed to produce
pronounced mental symptoms because they exert either
local or general pressure.

Schuster observes in his ex-

perience that those tumors lying nearest the cortex produce far more mental symptoms than those lying at a distance.

The
of

latter cause only a simple progressive disappearance the mental activity, indicating a cortical paralysis, while the former indicate signs of irritation.

The mental symptoms
varied.

of brain

tumor are naturally quite

Schuster in about fifty-six per cent of 775 cases of brain tumor accompanied by mental symptoms finds that these symptoms consist of a gradually progressive mental weakness. The patients become sleepy, inattentive,
forgetful,
easily,

unproductive

and are without

in thought, indifferent, fatigue either their characteristic energy or

prolonged work. Mental application calls for an unusual effort. They exhibit a degree of drowsiness and stupidity which may even extend to coma. In addition
facility for

to this, there develop the various symptoms indicative of tissue irritation and destruction, the character of which depends somewhat upon the situation and growth of the

tumor, such as apoplectiform attacks, convulsions, aphasia,
hemianopsia, etc.

Where

these

symptoms

are slight or

altogether absent, the picture may appear very much like a case of paresis of the demented form. In such cases the
differentiation

depends upon the absence of reflex pupillary disturbance and the absence of speech disorder. Other symptoms emphasized by Schuster are greatly
increased irritability with transitory periods of excitement, less often periods of despondency with delusions of per-

ORGANIC DEMENTIAS
secution

343

of the dorsal regions of the brain are apt to be accompanied by delirious states
self-accusation.

and

Tumors

with pronounced hallucinosis, although mental symptoms accompanying tumors of this region are less frequent than
in

tumors of the frontal

lobes.

Occasionally in brain tumors there exists a condition
of elation, even with distractibility of attention, productiveness, flight of ideas, and some increased activity; but more

frequently there exists a condition of childish happiness,

with a tendency to joking and punning. This mental state Schuster finds more characteristic of tumors of the
frontal lobes.
in brain tumor.

Finally the hysterical syndrome

may

exist

The

differential diagnosis in this state as well as in all of

those already mentioned depends almost wholly upon the presence and character of the physical symptoms,
indicative of focal lesions.

As regards

treatment,

one should

resort to anti-syphilitic treatment in cases of suspected
syphilitic

gumma, and
tumor

location of the

is

to surgical interference where the In suitable for such procedure.

recent years there is a gowing tendency to operate in all cases of cerebral tumor, if only for the temporary relief
of distressing symptoms. Brain Abscess. Brain abscess

be unaccompanied be of slow developby mental symptoms, particularly ment. In recent traumatic abscesses stupor is a prominent

may
if it

symptom. The patients are completely disoriented, and do not comprehend what is said to them. They are restless, Beresistive, and sometimes in a dreamy, delirious state.
sides this, there may develop catalepsy, aphasia, epilepsy, slow pulse, Cheyne-Stokes breathing, and other signs of
irritation.

Cerebral Apoplexy.

The mental symptoms

of cerebral

344

FORMS OF MENTAL DISEASE

hemorrhage, embolism, and thrombosis usually depend in small measure only upon the focal disorder. Immediately
following the apoplexy the patients are usually unconscious, completely disoriented, and perform all sorts of strange
acts.

Sometimes there develop transitory states of active excitement, with noisiness and display of resistance. These acute disturbances usually disappear in the course of a few

days or weeks, leaving as residuals the symptoms of the original disease process, which almost always is an arteriosclerosis

or

syphilitic

endarteritis.

The

patients

may

become wholly clear mentally, or may exhibit the various symptoms of arteriosclerotic or syphilitic insanity, already In embolism, the mental symptoms sufficiently described. and entirely disappear. However, the permay suddenly
sistence of aphasic or paraphasic disturbances
it

may make

appear that the patient exhibits
exists.

more marked mental

weakness than really 1 Cerebral Trauma.
head
injury,

widely a considerable group of cases. It has been decomprise monstrated that in cases of severe trauma there exist

Mental disturbances accompanying designated as traumatic insanity,

profound cellular changes in the cortex, and besides this, areas of contusion and punctate hemorrhages at a distance

from the point of injury, particularly on the
of the brain,

inferior surface

and

at the tips of the frontal lobes, in the

temporal and

occipital lobes.

insanity in the narrow sense comprises traumatic delirium and traumatic dementia (post traumatic

Traumatic

constitution,

Meyer).

Cerebral

trauma should

also

be

regarded as a prominent etiological factor in epilepsy and in the traumatic neuroses. Insolation is regarded as a

form of cerebral trauma.
Meyer, Am. Jour, of Ins., LX, 373 Guder, Die Geistesstorungen nach Kopfverletzungen, 1886; Koppen, Archiv f. Psy., XXXIII, 568.
1
;

ORGANIC DEMENTIAS
Traumatic
delirium

345

(primary traumatic insanity) dethe loss of consciousness incident to the velops following head injury. The patients, instead of becoming clear,
present befogged states with complete disorientation, difficulty of thought, and very little or no memory of the accident.

Sometimes the amnesia includes a period just preceding the accident, and not infrequently there is amnesia for other
isolated periods of the

poorly,

There
ally,

is

and have often a marked tendency

of the patients. They perceive difficulty in seeing the connection of things.
life

to fabrication.

Emotion-

they are

irritable or indifferent.

They

are apt to be

restless, at times aggressive, often whining and talking considerably, the content of the speech being rambling and

incoherent.
ent.

There

is

Delusions and hallucinations are rarely presno_jJej|r_infught Jnto^jthe.- disease, and the

patients speak of themselves as being perfectly well. This state is sometimes accompanied by transitory aphasic

The symptoms of traumatic delirium may last for many weeks, some cases persisting for several months,
states.

after which the patients usually recover, although sometimes the condition of traumatic dementia supervenes. In traumatic dementia there develops sooner or later after

the immediate effects of the injury, and in some cases even where there never has been a loss of consciousness,

a change of disposition.

This alteration
is

indefinite that all the friends can say

even be so that he is a changed

may

man.

This change usually consists of an increased susceptito fatigue; i.e. unusual fatigue upon slight exertion; bility some forgetfulness, confusion of thought, inattention, un-

wonted
dency

timidity, occasional slight despondency, with a tento complain of many disagreeable sensations, as dizzi-

ness, ringing in the ears,

head pressure, and a certain sense of heaviness and stupidity. Accompanying these complaints

346
there
is

FORMS OF MENTAL DISEASE

usually a keen sense of illness. The patient is irritable, irascible, and at times even exhibits some passion. Isolated convulsions sometimes develop, or even attacks

Not only a tentemporary dazed spells. dency to alcoholism, but also a striking intolerance to
of petite mal, or

the influence of alcohol and other drugs, often appears, as well as great intolerance to the sun's rays. The capacity for employment is impaired, in explanation of which the patient refers to various subjective sensations. Even games and conversations are avoided for the same
reason.

The
but
is

course of the disease

is

not distinctly progressive,

Many

sometimes characterized by distinct exacerbations. of these exacerbations can be traced to alcoholic

indulgence or trivial emotional causes. Deterioration is most pronounced where the trauma is associated with
alcoholism
or
arteriosclerosis, or

where

the

injury has

occurred during youth. Usually there are some nervous manifestations indicative of focal lesions of the brain, such
as changing pupillary disorders, tremors, paresis of facial muscles, and exaggeration of the tendon reflexes. There

are a few cases of traumatic dementia which for a time
like paresis,

may

appear by the changing character of the pupillary disturbance

but are differentiated from this disease

and the relatively slow progress of the disease. Undoubtedly some cases of paresis do develop from brain trauma as a starting-point. This, however, is a mooted point, yet there are many observations, including those of Meyer and Koppen, which indicate its validity. Some of the doubtful cases of traumatic dementia, simulating paresis, have presented on post-mortem examination an extensive arteriosclerosis
characteristic speech disorder,
of the brain.

and the

ORGANIC DEMENTIAS

347

treatment of traumatic insanity rests in early cases with operative procedure, particularly where there is an
indication
of focal

The

disorder.

In

traumatic

dementia,
indications

surgical interference,

even though there
far less successful.

may be

of focal irritation,

is

VIII.

INVOLUTION PSYCHOSES

forms of mental disease, described as involution psychoses seem to bear some relationship to the general
physical changes accompanying involution. Undoubtedly, the forms of mental disease included here can occur in other

THE

periods of life, also there are many other psychoses unrelated to involution that may occur during the involution period; as for instance, the alcoholic and infection psychoses, manicdepressive insanity, etc. The mental disturbances of the early involutional period are of a somewhat different stamp

than those characteristic of

senility,

symptoms common

to both.

though there are many Those occurring in the former

period are called melancholia and presenile delusional insanity, and in the latter, senile dementia.

A.

MELANCHOLIA

1

Melancholia

is

restricted to certain conditions of mental

depression occurring during the period of involution. It includes all of the morbidly anxious states not represented in other forms of insanity, and is characterized by uniform despondency with fear, various delusions of self-accusation, of
persecution,
1

and

of

a hypochondriacal nature, with moderate
;

v. Krafft-Ebing,

Die Melancholic

Christian,

6tude sur

la Me*lancolie,

1876; Voisin, M&ancolie, 1881; Dumas, Les Etats Intellectuels dans la Melancolie, 1895; Roubinowitsch et Toulouse, La Melancolie, 1897. Hoch, Rev. Ed. of Reference Handbook of Medicine, p. 117.
la

De

348

MELANCHOLIA

349

clouding of consciousness, leading in the greater number of
cases, after
tion.

a prolonged course,

to

moderate mental deteriora-

Etiology.

The
sixty.

disease

is

essentially

senile period, as the majority of cases occur

one of the early between the ages
in

of fifty
sixty.

and

It

seldom develops under forty or over

Sixty per cent, of the cases are

women,

whom the

disease tends to occur

somewhat

earlier,

some

relation

to

the

climacterium.

apparently bearing Defective heredity

occurs in only a little over one-half of the cases, but it is a striking fact that the parents and brothers and sisters of melancholiacs frequently suffer from apoplexy, senile de-

External influences, such as mental shock, especially illness and loss of friends, acute and chronic diseases, and surgical operations, seem to play a
mentia, or alcoholism.
rather important role as exciting causes of the disease. In many cases there is found Pathological Anatomy.
extensive arteriosclerosis

and kidneys.
atrophy.
cortex, in

and its attendant results in the heart Sometimes there is evidence of beginning brain Alzheimer found, in the deeper layers of the addition to the changes in the nerve cells, an exis

tensive

production of the neuroglia. The onset of the disease Symptomatology.
fibril
is

gradual,

and

months and even years by many indefinite prodromal symptoms; such as, persistent headache,
often preceded for
appetite, constipation, palpitation of the heart, ringing in the
ears,

vertigo, indefinite pains, general debility, insomnia, loss of

and increasing difficulty with work. The patients at first become sad, dejected, and apprehensive, and find no enjoyment in their work or home environment. They are overshadowed by doubts, fears, and self-accusations, and cannot be consoled.
confused,

They feel ill, complain of being dull, and forgetful, and find it difficult to do anything.

350

FORMS OF MENTAL DISEASE

During this period there are occasional days when they are free from fear and sorrow.
Delusions of self-accusation become prominent. Sometimes the patients accuse themselves only in a general way:

they are wicked, are not worth anything, have made fools of themselves, have been impure, and are not worthy to live.

But usually the self-accusations refer to definite experiences. Patients become retrospective, and refer to many misdeeds in going over the past life which are held as an adequate Remote and often insignificant facts basis for their sorrow.
are recalled, such as the stealing of fruit in childhood, disobedience to parents and neglect of friends, which now cause them the greatest sorrow and anxiety. Their whole life has been made up of similar misdeeds. patient was miserable

A

because she had requested her sick sister to remain out of the kitchen another, because at the death of her mother she had
;

allowed
property.

herself

to think of

and mention the

division of

Many

refer to former sexual indiscretions.

Some

patients reproach themselves for everything; they cannot do anything right. Everything in the environment is a

source of special anxiety to themselves; the lamentations of a fellow-patient are directly the result of their own misdeeds.

Others want for food

if

they

eat.

These references vary from

day to day, or may be maintained with great firmness for a long time. Quite often the self-accusations refer to religious
patients are not as fervent in prayer as formerly; they no longer possess real religious feeling, or have sinned against the Holy Ghost, are possessed by the
experiences.
devil, etc. Occasionally their self-accusations center about actual misdeeds, which during health long since ceased to cause anxiety.

The

In addition to these self-accusations the patients sometimes harbor the conviction that they themselves must be

MELANCHOLIA
killed or that

351

one of their children

is

to be sacrificed.

" furthermore, are constantly rinding "signs" and meanings" which God has intended for them. There are often associated with these delusions of self -accusations

They,

many

other

depressive delusional ideas, chief among which are the fears The patients believe themselves so wicked of punishment.

that

God has

forsaken

them and they

are

doomed

to hell,

they will be turned out of their home, brought to court, thrown into prison, or killed outright. People are waiting
outside to carry

them

off,

a death warrant

is

already signed.

no need of taking food; they would rather starve and suffer for their misconduct, and even ask to be executed. Not infrequently they exaggerate their misdeeds and confess crimes which they have never committed, in order to
There
is

secure severer punishment
sciences.

and

to relieve their guilty con-

In other cases the delusions are of
driacal nature.

a more hypochon-

Patients insist that they are the most unfortunate individuals in the world; the stomach is gone, the lungs are filled up, the limbs shrunken, and all sensation
lost.

The brain and nerves
They

former sexual abuse.

are rotting away as the result of fear that they are dying of con-

sumption or cancer, and that they are going out of their minds and must end their days in an asylum. They maintain that the body has been poisoned, destroying all appetite, and now
they must starve. They also express considerable fear for themselves and families; they will be deprived of their home, some great calamity will visit them, the children will

they themselves will be robbed and driven from the church and damned by God.
die, or

killed, will

be

These depresrefuse to spend

sive delusions so thoroughly influence their actions that they

become

seclusive, eat sparingly or not at

all,

money, and

clothe themselves

and

their children scantily.

352

FORMS OF MENTAL DISEASE
give

They
to

up everything because they have only a

short time

live.

Hallucinations of hearing and sight often accompany this condition, but they are usually indefinite and of short dura-

The patients also refer to an inner voice which commands them to commit suicide, or constantly repeats to them that they are wicked and guilty. The consciousness is usually clear. The patients are well oriented, with the
tion.

possible exception of

some delusional

ideas, in accordance

with which they may claim that they are in a prison, or they may mistake strangers for acquaintances and insist that the
letters

ideas,

which they receive are not real; but in spite of these it may be readily seen that apprehension itself is not
disordered.

much

is coherent and relevant, but the content is usumonotonous and centered about the depressive ideas, to ally which they constantly recur, recounting their various misdeeds and fears. Very often they show a tendency to repeat

Thought

certain phrases, as

"

Let

me

go home,"
"
I

"

Let

me

go home;

"

"

I

want to
is

see

my

children,"

want to

see

my

children."

There

usually some insight into the change which they have undergone and they will complain that their head is not right,

but they
such.

fail

to recognize

many symptoms

of the disease as

a smaller group of cases of melancholia of involution occurring somewhat later in life, in which the various
is

There

delusions of self-accusation, of fear, misfortune, and persecuIn these cases tion are much more fantastic and senseless.

the entire environment appears to the patients to be changed. Their home is transformed into a dungeon, into a house of ill
repute, or a deserted prison

escape.

from which there are no means of Things about them seem unnatural and have a

gloomy aspect; passing carriages are regarded as a funeral

MELANCHOLIA

353

procession; the tolling of the church bell indicates that some one has died. A spoon lying on the table means that medicine has been taken

by some one who
nails

is

now

at the point of

death.

Hammer and

found on the

floor signify that

a

scaffold is being secretly built for their execution. Chance remarks have a hidden meaning. Their food is the flesh and blood of their relatives. Everything is awfully changed for

them; friends and
are

relatives are not real;

the sun and the

moon look different; the end of the world has come; and they now to be passed into a lion's den. The patients accuse

themselves of horrible crimes, for which they are exiled or must die on the gallows; have murdered their husbands,

devoured their children, or have brought sin upon the whole world. All wickedness is due to them ; they have desecrated the communion bread, or have spat upon the image of Christ.

They

are totally unworthy, should be buried alive, no one should speak to them, hanging is too good, and they should

be thrown into molten metal. In some cases the so-called "
nihilistic delusions" (delire

de negation) predominate, when the patients claim that nothing exists, there is no more food, no more houses, no more trees, no cities, no day or night, no sun or moon, no
living being.

They

are alone in the universe, as there

is

no

They themselves have no name, no wife, no children. cannot eat, cannot speak, cannot die. Their body is all They shrunken up, their bowels never move, and food has been
world.

accumulating in them for months. They no longer possess a heart or lungs; they cannot breathe or even walk.

Extremely absurd hypochondriacal ideas are apt to be expressed. The patients claim that they have no breath, the
blood has stopped circulating, the veins have dried up, the eyes are rotting away, maggots are crawling under the skin,
their brain
is

solid rock, their limbs are

transformed to hoofs

2A

354

FORMS OF MENTAL DISEASE
face to that of a wild animal.

and the

Occasionally sexual

delusions of a silly character are present, the patients

main-

taining that they have been outraged at night, are now in a house of ill repute, or surrounded by men disguised as women. These depressive delusions are definite, coherent,

and usually

well-retained.

There are a few

cases, especially

those with progressive mental deterioration, in which a few expansive delusions appear.
Hallucinations, especially of hearing, and also of sight are prominent. Voices and bells are heard, the devil commands

them, strangers insult them, and they hear the evil thoughts of others. They see strange forms beside them at night,

moving bodies and spirits. Occasionally they detect strange odors and tastes in food, and smell vapors at night. Consciousness in these cases is usually clouded and there is some disorientation for time, place, and persons. The train of thought is somewhat confused and monotonous, with a
tendency to repeat compulsively such phrases
I
it

do?"
is

"What

did I

do?"

"My God
how

!

What did my God !" Yet
as,

"

sometimes surprising to find

well patients answer

questions and describe their symptoms. Sometimes the patients are partially conscious of the nature of their illness

and complain that they have been made

foolish

and crazy by
In other

poison placed in their food or hypnotic influence.

cases the patients are wholly unable to recognize the contradictions in their absurd statements: at one minute they will

claim that they have been destroyed by poison, and at the next that they cannot die. The emotional attitude is uniformly one of depression. The
basis for this emotional depression seems to be fear, a feeling
of oppression,
it is

an inner

anxiety.

Some

patients claim that

a heavy weight were upon the chest. They are timid, uneasy, and feel as though homesick. The fear is
as
if

MELANCHOLIA
increased

355

by

association with those

who

are accustomed

to arouse in

them the deepest
create
little

feelings, while strangers

and

new environment
tional outbreaks

emotional reaction.

Emo-

may be present at times, when the patients are greatly agitated, and may even present a dreamy disturbance of consciousness. These frequently follow visits of
relatives or

some unusual occurrence.

In conduct, the patients no longer feel the impulse to work; work is hard to finish. Yet they cannot remain quiet, they cannot remain in bed, and wander about the house in an

They complain, lament, and pray; visit and the clergy in order to receive sympathy, physicians although they know that no one can help them. Many
aimless manner.
patients develop a feverish activity, they beg piteously for work, they work at night and struggle along until

completely exhausted their sorrow and fear.

in

order to take their minds off

The countenances
their anxiety.

of the patients give clear evidence of

Occasionally in very severe cases there

may

appear transiently no means represents an elated emotional

a

peculiar indefinite laughter,
state,
feel

which by but is rather

an expression

of desperate irony.

They

compelled to

talk about their condition.

They always have something to communicate to the doctor, but one finds that it is always the same old story. It is a striking peculiarity that these patients become quiet when transferred to a new environment. They become natural in their manner, are approachable, and
are able to conceal their anxiety. They claim that everything will be all right again if they could only return home and to

work, but careful observation shows the real depth of their emotional excitement. After the disease has been in existence some time, the patients may be able to remain quiet and more or less indifferent for a much longer time. But as soon

356

FORMS OF MENTAL DISEASE

as one comes into close companionship with them, he will observe occasional evidences of emotional outbursts.

Commands
create
free

are carried out without delay, unless they

some anxiety. The individual movements are usually and unrestrained, although they are usually performed

without any special strength or rapidity, especially in patients much reduced physically. There is no striking disorder in
writing.

and many even refuse food sometimes because they wish to die, at others altogether, because they are not worthy of food. Others suspect poison or excrement in their food. Similarly, patients refuse to
patients eat irregularly

The

take medicines and to bathe themselves.

Some

patients are

untidy and even soil themselves. The tendency to commit suicide is more pronounced and more to be guarded against in melancholia than in any other form of mental disease. The desire to end life may be the

outcome of deliberation, or because they are repudiated by God. But usually the thoughts of death arise suddenly and
are
impulsive. Not infrequently they suddenly develop during convalescence. Often their attempts at suicide are

not remembered. Sometimes the suicidal attempts are among the first symptoms of the disease. Every melancholiac should,
therefore, be regarded as a dangerous patient,
so,

and the more

the more conscious he
his

is

ing

anxiety. patients resort to all sorts of devices to accomplish their purpose. Some attempt to drown themselves in the bathtub, others

Determined to

and the more capable of concealcommit suicide, these

ram

their heads against the wall;

many hang

or

their necks.

attempt to strangle themselves by tying something about In their agitation they seem to be quite insensible to pain. One of my patients reduced her scalp to

pulp with a hammer, fracturing her skull in several places.

MELANCHOLIA
Other patients swallow that they can secure.
glass, nails, ink, or in fact

357

anything

In case the anxiety is accompanied by greater excitement, the patients cannot remain quiet, but pace back and forth,
wringing their hands, pulling at their hair, moaning and lamenting until so hoarse that they can barely speak aloud. In their great anguish they persistently pick at their nose,
face, or fingers until

smeared with blood, pull out their

and pound themselves. Kraepelin whether this extreme picture really belongs to questions melancholia or should be classified in a group as yet unThese cases, anatomically, usually present differentiated. severe and extensive lesions in the cortex in which there
hair, tear their clothing,
is

destruction of very

many
sleep

nerve

cells.
is

Physical Symptoms.

Insomnia
is

nent symptom.

The

an early and promiscanty, much disturbed by

dreams, and unrefreshing. Occasionally there are observed the early signs of the senile changes; such as attacks of dizziness, sluggish pupillary reaction, paresis of the facial
muscles, and tremor of the tongue

and hands.

The

patients

also complain of uncomfortable sensations about the heart;

" a sort of tension, a pressure, or an anxious feeling," which The muscular power is diminis regularly worse at night.

ished and there
nutrition suffers

The is some general physical weakness. and the weight falls. Appetite is poor or

completely lacking, the bowels are very sluggish, the tongue The mucous surfaces are coated, and the breath foul.
anaemic.

The temperature frequently remains below normal.

Circulatory disturbances are often present; as, cyanosis, The pulse may be coldness and edema of the limbs. small and irregular or slow, and the arteries may give

evidence of

beginning

sclerosis.

Other changes, indica-

tive of senility, are sluggish reaction of pupils, grayness of

358

FORMS OF MENTAL DISEASE

the hair, cessation of the menses, dryness and harshness of the skin.
Course.

There

is

duration, and a
of recovery the

still

more gradual convalescence.
lasts at least

a gradual development, a prolonged In cases
twelve months to

whole course

two

Short remissions, during which there is only a years. partial disappearance of the symptoms, are characteristic of

the entire course.

There

is

ment toward evening, and
during the morning.
of annoyance, fatigue,
visits.

often present a daily improvean exacerbation of the symptoms

Exacerbations often arise as the result

and

excitation, such as that

induced by

nutrition, gradual improvement an increase in weight, may be regarded as a favorable sign. The remissions become longer and more marked, and the anxiety gives way to irritability and fretfulness; the patients then begin to display interest in work and reading.

A

of the sleep

and

especially

Even when convalescence is well established, it is not unthem to have " bad days," during which they are troubled and fearful. The distinguishing characteristics of melanDiagnosis.
usual for

slow development, uniform course, long duration, gradual improvement, and doubtful
cholia
of

involution

are

a

the

These characteristics only partially suffice for of melancholia from the depressive of manic-depressive insanity. In addition, the disphase
prognosis.
differentiation

quietude of the melancholiac
dejected and hopeless
patient.

is

contrasted with the

more

attitude of
is

This difference

the manic-depressive especially well marked in the

early stages of the disease,

when the melancholiac shows

more
cholia

clearly anxiety

sive patient

the

and restlessness and the manic-depresa dismal despondency and sadness. In melanemotional attitude is much more uniform.

Although the melancholiac

may show some

variation in the

MELANCHOLIA
intensity of his feelings, the anxiety
is is

359

not possible, as

it

sometimes

is

always present, and it in manic-depressive in-

by consoling or joking with them, to make them cheerful and smiling. Furthermore, in the psychomotor field we do
sanity,

not observe the retardation, which
in manic-depressive insanity.

is

usually so pronounced
diffi-

The

patients have no

culty in expressing themselves orally or

by writing
If

;

they are

unhampered

in their

movements and

actions.

they hap-

pen to be silent and refuse to speak, it is evident that this arises from their desperation or their delusions. They are
usually communicative can secure consolation.

and

talkative

enough whenever they
in

some of the mixed phrases of manic-depressive insanity, in which the despondency is associated with some excitement and not with
differentiation is

The

by no means as easy

retardation.

In such cases the distinction depends upon the
irritable, is

fact that the emotional state in the
less

anxious than

mixed phases is usually accompanied by grumbling and

at times

faint-heartedness, that restless patients can be influenced by conversation to become quiet and even easily cheerful, and finally, that the excitement is not an expression
of the feelings, but
in

an independent disturbance which stands

no

The
is

relation to the intensity of the feelings. depression of catatonia developing during involution

distinguished from melancholy by the presence and persistence of hallucinations and the inaccessibility of the patients. The melancholiac is resistive and inaccessible only in con-

nection with his anxiety or his delusions. He is usually influenced by conversation, and participates in the conversation

when

visited

by

friends,

while the catatonic shows

emotional indifference, negativism, and constrained and manneristic conduct. The uniform lamentation and wringing of the hands in melancholia contrasts with the senseless

stereotypy of the catatonic.

360

FORMS OF MENTAL DISEASE
characteristic
of
senile

Symptoms

dementia sometimes

develop in melancholia, rendering the prognosis less favorable. Such symptoms are, chiefly, the interference with the
impressibility of

memory, the tendency

to fabrications, loss

of orientation, emotional indifference, silly obstinacy,

and

nocturnal restlessness.
of delusions
is

The

fantastic

and

nihilistic

character

not an unfavorable sign, but senile physical changes are; namely, decrepitude, atrophic changes in the skin, bones, and muscles, and the evidences of arteriosclerosis
in the heart

and

vessels.

Melancholia has no connection with the arteriosclerotic
brain lesions.

The depressed

states occurring in arteriosck-

rotic insanity are distinctly

hypochondriacal and accompanied by evidences of dementia and of severe brain lesions. Considerable trouble may be experienced in differentiating

the depressed form of dementia paralytica. In melancholia one finds a subacute onset following definite prodromal

symptoms, greater or

less clouding of consciousness, a more consistent emotional attitude, and absence of evidences of mental deterioration early in the disease, while in dementia

paralytica there

a gradual onset with early evidence of mental deterioration, defective time orientation, poor judgis

ment

and contradictory delusions. silly the emotional attitude does not always corFurthermore, respond with the ideas expressed, and consciousness is more
and
memory,
deeply clouded.

The prognosis is not favorable, considering Prognosis. that only one-third of the cases fully recover. Twentythree per cent, of the cases improve so as to be able to return

home and
tenance of

live comfortably,

sometimes aiding in the main-

the family, twenty-six per cent, become deand nineteen per cent, die within two or three years. mented, The patients, being apathetic and anergetic, and taking little

MELANCHOLIA
exercise

361

ated, tious or chronic disease.

and insufficient food, become more and more emaciand finally succumb to cardiac weakness or some infec-

The prognosis is less favorable in cases occurring after fifty-five years of age. In those cases that improve, but do not recover, the depression

and the delusions gradually disappear, and the consciousness becomes perfectly clear, but the patients fail to develop full interest in the surroundings and to adapt themselves to any kind of work. They are dull, sluggish, and In those indifferent, and tend to be low spirited and tearful. delusions fade very graduthat become more demented the ally, but the patients fail to gain insight and show poverty of thought. They are forgetful, apathetic, and entirely unable
to apply themselves. They stand around stupidly or lament Others develop the typical in a monotonous fashion. picture of senile dementia. Residuals of former delusions,

as well as a few hallucinations

and some expansive

ideas,

remain.

Treatment.
"

The
all

chief essential is the establishment of a

rest cure," which, first of all,

demands the removal
influences,

of the

patients nearest relatives, the

from

deleterious

home

it is occupation. patient to a sanitarium or hospital. urgent if suicidal tendencies develop.

Hence

including the environment, and the customary usually necessary to send the

This

is

particularly

It is necessary in most cases that the patients be confined in bed with short intermissions, with sufficient and constant

attendance.

the patient can be confined in bed out of doors in a secluded, partially sheltered, and sunny place,
If

be found decidedly beneficial. It aids in alleviating insomnia and affords a more interesting and attractive
it

will

In very light cases a suitable change may be found in removal to a different boarding-place or into the
environment.

362

FORMS OF MENTAL DISEASE

associations of a happy family. It is decidedly not advisable to attempt such distractions as might be afforded by long journeys, sight-seeing, and constant company. The rest in

bed should not be too prolonged; later it is best that it be gradually replaced by short drives or walks, combined with
daily change of scenery.

Of next importance

is

nutrition.

nutritious, given in small quantities

The food should be and at frequent intervals.

Monotony
combined,

in diet should always be avoided

tastes of the patient.
if

by consulting the Careful regulation of the intestines,

proves the appetite.

necessary, with rectal injections, usually imExtreme anxiety and restlessness often

necessitate artificial feeding

by stomach or nasal tube

in

order to maintain nutrition.
cardiac weakness,
to overcome,
it is

When this is contraindicated by

Insomnia, which
is

is

necessary to resort to saline infusions. both troublesome and often difficult
first

best combated at

by prolonged warm

baths in the early evening, warm packs, or gentle massage provided it does not increase the agitation. Hot malted

milk before retiring

may

aid in inducing sleep.

These

measures, well carried out, often render hypnotics unnecessary, the use of which is always inadvisable because of the

prolonged course of the disease.
is

Of the hypnotics, alcohol
fluid

the most

useful.

Paraldehyde, one-half to one

$ram, and one-half

trional in ten to fifteen grain doses, veronal seven
grains,

and somnos are the most

useful.

distressing condition of anxious restlessness may be combated with opium. It is best given in rapidly increasing

The

doses beginning with five drops and reaching thirty to fifty drops of the tincture of opium three times daily, which is

gradually reduced as soon as the restlessness begins to subside. This drug sometimes not only fails, but serves to aggravate the symptoms,

when

it

must be withdrawn gradually.

MELANCHOLIA
Improvement from this source,
a few days.
careful,
difficult to
if it is

363

to occur, appears within

Suicidal tendencies

necessitate

painstaking,

and constant watching, as melancholiacs are the most

thwart in their attempts at suicide. This care must be as strenuously observed until recovery is well established.

The psychical influence which may be constantly exerted over the patients by those in attendance is of the greatest value in alleviating distress, modifying the delusions, and
relieving the anxiety.
gentle,

For

this reason the

manner should be

friendly, and assuring, and some attempts should be made to lead the thoughts of the patients away from always As the patients improve there should their depressive ideas.

be a systematic effort to gradually engage them in some
light

employment, as sewing, reading, writing,
relatives are always deleterious

etc.

Visits

from

and
it is

in the height of the of the

disease

must be forbidden

Finally,

utmost im-

portance that the patients be kept under observation and safe index of this treatment until thoroughly recovered.

A

may

be found in their insight into the disease and the

return of normal sleep and nutrition.

B.

PRESENILE DELUSIONAL INSANITY
a small group of cases appearing during involu-

THERE

is

tion which are unlike either melancholia or senile dementia,

showing many of the characteristics of dementia praecox. It has been tentatively differentiated and characterized by the
of marked impairment of judgment, numerous unsystematized delusions of susaccompanied by picion and greatly increased emotional irritability.

gradual

development

Etiology.

The psychosis

is rare,

times in ten years' experience. The are women, in whom the disease appears between
to sixty-five years of age; while in There seems to be fiftieth year.
disposition to the disease.

occurring only twelve majority of the cases
fifty-five

men

it

occurs about the
pre-

marked hereditary

The onset of the disease is gradual, Symptomatology. with a change of disposition. The patients at first become
quiet,
ritable.

seclusive,

Then and transitory, but vague
definite.

discontented, moody, suspicious, delusions gradually develop which at
later

and
first

ir-

are

become more permanent and

driacal delusions.

appear are the hypochonpatients complain of the most varied and changeable nervous sensations and pains, spasmodic

Among

the

first

to

The

twitchings, vertigo, troubled dreams, debility, malaise, roaring in the ear, etc., which remind one of hysterical

complaints.
senseless,

These ideas
all

later usually

become somewhat
is

and the

patients complain that the spine

dried

up, the brain shrunken,

strength has departed,
364

etc.

PRESENILE DELUSIONAL INSANITY

365

Meanwhile, fantastic delusions of suspicion appear. The patients claim that their clothing has been exchanged or stolen; that articles of furniture have been removed and
others of less value substituted;
thieves are about.

They

suspect poison in the food; accuse the physician of trying to get rid of them, of being obscene, of removing the womb,
or making them ill for the purpose of studying their case. The husband believes that the wife is secretly dosing him. Delusions of infidelity are usually very numerous and prominent. The husband is accused of eying women on the
street, of flirting

servant,

and receiving

with every one he meets, of caressing the letters from the schoolmates of his

He arranges to meet women whenever he leaves and has intercourse with every one possible. The home, husband is suspicious of his wife because she leaves him at
daughter.
night, or is surprised

when he

returns

home

It is characteristic of all these delusions that

unexpectedly. they are

exceedingly unstable. They appear at one moment, are abandoned in the next, and again recur in another form. As regards insight, many patients admit that they might have

but they fail to really appreciate the senselessness of their ideas. Half an hour later you may find them in the greatest distress, because they
sick,

been mistaken and that they are

have been poisoned, or because some one has hidden under the bed ; they are going to die, etc. soothing word usually suffices to quiet them and dispel their fear.

A

Hallucinations
cases.

accompany the delusions

in only a

few

patients are sometimes threatened, or hear boast of intercourse with their wives. The cries strangers of their ill-treated children reach them. At night they may see dark forms stealing out of the room, or feel some one lying

The

beside their wives.

It is a noteworthy fact that the patients do not make a genuine attempt to intercept these guilty

366
parties.
If

FORMS OF MENTAL DISEASE
a search
is

instituted

and they

fail

to find

one, they express anger only because connubial fidelity violated with such shamelessness and slyness in their

any was

own

presence. Consciousness

Thought is noted in the retention of the most fantastic delusions, while the consciousness of the patient is perfectly clear. The
patients cannot see the senselessness of the delusions, and while they may claim that they are open to conviction, they can never be convinced. Their memory for remote events is

unclouded and orientation unimpaired. coherent, but judgment shows a marked weakness,
is

unimpaired.

However, in the narration

of their delusions,

they add

all sorts of

The

emotional attitude at first is
it

embellishments and misrepresentations. one of depression and fear;
to
suicidal

occasionally

leads

attempts.

Later there

usually appear some excitement and irritability. The patients then talk a good deal, make verbose complaints, stir up boisterous scenes, fly into violent passion, and are abusive, but they are usually quieted without difficulty. They sometimes laugh and cry without cause. The conduct is characterized by all sorts of senseless
actions.

In accord with their delusions

many

patients run

about from one physician to another, and solicit much advice without attempting to follow any of it. Some stop
eating, seclude themselves, destroy everything within reach, and become violent. Jealousy leads to strict surveillance of

the husband or wife.

The servant

is

sent out in search of

them; torn letters in the waste basket are placed together in order to obtain proof of guilt, and the supposed seducers may
be publicly accused. With the advance of the disease the delusions become more
senseless; the patients claim that the wife

being tortured, the son nailed to the

floor,

and children are or suspended on a

PRESENILE DELUSIONAL INSANITY
fence;

367

the wife wanders nightly from place to place, and every one is talking about it. Female patients believe that their husbands have intercourse with their own children, and

even with other men, disguised as women.

They

are aware

of this only through sensations in their own bodies, whenever they are deceived. The precious Lord proclaims

everything, talks to them, and lies beside them at night like a shadow. Persons and the environment are changed; their bodies are disfigured and influenced. For this reason, many
patients remain in seclusion, veil themselves, and at times refuse to speak and then suddenly become very friendly and

These delusions frequently change, and may temporarily fade away, although some general signs of them are constantly recurring. In spite of progressing
communicative.

mental deterioration, the patients do not become incoherent. Some regard these cases as paranoia, but they Diagnosis.
certainly differ

from paranoia,

in that the delusions are not

systematized. frequently, the

The

persecutors remain indefinite or change suspected consorts are not regarded as

enemies, but are often thought to have been seduced. Moreover, the patients do not find in their delusions any broad
basis for action,

and except

for their occasional violent out-

breaks, do not treat the supposed persecutor as especially they associate with their faithless wives, in fact even force themselves into their company, and surprise one
hostile;

by becoming
just

friendly toward those persons

whom they

have

previously suspected and accused.

They

often prefer to

be confined in the hospital in spite of complaining of all sorts of persecution, because they enjoy the protection afforded

them

there.

Finally, the delusions

do not continue

stable,

but change frequently, and sometimes even in a short time. The conditions of excitement seem to depend less upon
deliberation than emotional vacillations.

368

FORMS OF MENTAL DISEASE
consider these cases of dementia prcecox, which

Some

may

occur at this age, although not frequently. These patients do not present catatonic symptoms. The peculiar resistiveness and excitement occasionally manifested are not compulsive or spontaneous, but depend upon delusions or

moods.

The

patients do not

on the contrary,

become apathetic rapidly, but, continue irritable and interested, while

disturbances of judgment greatly predominate over those of the emotions and actions.
Prognosis.

The outcome

is

never

characterized

by

profound dementia or confusion of speech, but by a moderate deterioration, with isolated, changeable, and incoherent
delusions.

Recoveries or marked improvements are not

likely to occur.

Treatment.

The

treatment

is

wholly

symptomatic.

Most patients are troublesome and need hospital treatment, but some, under favorable conditions, are able to remain at

home.

0.

SENILE DEMENTIA 1
is

SENILE DEMENTIA
volution

characterized by

a gradually progres-

sive mental deterioration, occurring during the period of in-

and accompanied by a
It

series of lesions in the central

nervous system.

comprises several groups of cases, in-

cluding simple senile deterioration of lighter
grades, presbyophrenia, sional insanity.
Etiology.
involution,
senile

and severer
senile

delirium,

and

delu-

The
but
is

disease

may appear

at

any time during

sixty

and

encountered most frequently between Individuals with a seventy-five years of age.

endowment, worn with hardships, and may succumb before Men who have been more exposed to overwork and sixty. excesses develop the disease earlier than women. Defecfaulty constitutional
especially those addicted to excesses,
tive heredity occurs in

about

fifty

per cent, of cases, but

is

confined

mostly to senile deterioration in parents and in
sisters.

brothers and

Very frequently the disease develops immediately following an injury, particularly head injury,
shocks, also acute influenza and bronchitis.

emotional

febrile

diseases,

especially

1

Fuerstner, Archiv

f.

Psychiatric,

XX,

2

;

Noetzli,

Uber Dementia
f.

Senilis, Diss. Zuerich,

1895; Alzheimer, Monatsschrift
Scholoess,

Psychiatric u.

Colella,

u. 10, 1899; Annali di Neurologia, 1899, 6; Zingerle, Jahrb. f. Psychiatric, XVIII, 256. Pickett, The Jour, of Nervous and Mental Disease, 1904,

Neurologie, 1898, 101;

Wiener Klinik,

XXV,

9

p. 81.

2B

369

370

FORMS OF MENTAL DISEASE
All

Pathological Anatomy.

advanced cases of

senile

dementia present, both macroscopically and microscopically, atrophy of the nerve substance. The brain weight is from

two hundred to

five

hundred grams below normal.

There

may

be compensatory thickening of the cranium, and in-

The dura

crease of the cerebrospinal fluid (hydrocephalus ex-vacuo). The Pacis usually adherent to the calvarium.

chionian granulations are increased in size. Pachymeningitis interna hsemorrhagica is often present, and sometimes
to

an extreme degree.
over
the

The pia

is

somewhat thickened

uniformly

entire

cortex,

may

contain

many

corpora amylacea, and is almost always edematous. The convolutions are narrow and shrunken, and the gaping Minute fissures contain blebs filled with serous fluid.

hemorrhages are sometimes found in the cortex, corona

and basal ganglia. The ventricles are much dilated and ependymal walls thickened, and occasionally granular. The choroid plexuses usually present various stages of cystic The cerebral vessels exhibit arteriosclerosis, degeneration. in which there are often evidences of hyaline changes, but it is more characteristic of the vessels in senile dementia to show a rich pigmentation of the endothelial and adventitial cells. The fact that the blood vessels, in simple senile deterioration,
radialis,

are only moderately involved, favors the view that the vascular changes in senile dementia cannot be regarded as the particular cause of the disease. Further proof of this is

found in the fact that there are
sive vascular lesions of the

many individuals with extenbrain who do not exhibit signs
more or
less extensive,

of senile dementia.

Nevertheless,

vascular

lesions

commonly accompany

senile

dementia.

There occasionally occur combined forms of senile and " senile dearteriosclerotic insanity, called by Alzheimer

cay"

(see p. 334).

SENILE DEMENTIA

371

Microscopically, the nerve cells present different grades of the chronic cell change in addition to much pigmentation.

Complicating the chronic
those acute
cell

cell

change there

may

occur any of

changes described in paresis (see p. 282). Both the tangential and radical fibre tracts in the corona

present more or less atrophy. The neuroglia cells are more numerous and show an increase in the number of nuclei,

the

cell

bodies often forming distinct clumps (raseri) with a

thick network of fine glia fibrils. Many of the neuroglia cells show evidences of extensive degenerative processes; such as,
vacuolization,

nucleus.
cells

marked pigmentation, and atrophy of the The spinal cord presents an atrophy in its ganglion
fibre tracts.

and

Calcareous placques are sometimes

The entire pathological picture, however, pia. as well as the clinical picture, but as yet it is impossible varies, to establish any definite relationship between the different
found in the
pathological and clinical pictures. The other organs of the body present senile atrophy and arteriosclerotic changes. The condition of the heart, with

chronic endocarditis and fibroid changes in the myocardium, is of importance, as it interferes with cerebral circulation.

Symptomatology.: The apprehension of external impressions is slow and difficult. The patients fail to note
details

and to understand the connection of things that are complicated. They, therefore, become easily disoriented, cannot see the point in a discussion, and overlook important matters. They are drowsy, disinclined to think, somewhat dazed, and easily lose the thread of a conversation. Thought becomes stagnant and the patients are unable to change their viewpoints or to gain new ones. The old trains of thought,
being inaccessible to new ideas, do not get beyond the beaten paths. Ideas, once aroused, are constantly recurring, without any regard for the circumstances.

The mental

elabora-

372

FORMS OF MENTAL DISEASE

tion of external impressions, the consideration of cause and effect, and the critical examination of ideas is always in-

adequate and uncertain.
total inability to

This

explains

the

7

comprehend the views and

patients conditions of

others, as well as the inflexibility of their opinions

and

their

Their delusional ideas susceptibility to delusional ideas. consist mostly of excessive fear of illness, senseless distrust, or childish egoism. Other prominent delusions are those of

and robbery. They commonly believe that many are done to annoy them and that their property has things lack of genuine insight into been taken from them.
reference

A

their infirmity, necessitating the

appointment of a trustee

or

conservator, creates still other ideas of persecution. Hallucinations and especially illusions are common.

The

failure of

memory

is

especially

memory

for recent events.

always a prominent symptom, Present and passing

time seem to be completely effaced from memory. Patients forget where they were yesterday, or where they have placed things, do not realize that they are relating the same story that they told yesterday or perhaps a few hours ago, cannot recall the names of recent acquaintOn the ances, and even forget the names of old friends.
events, within a short

other hand,
of recent

memory

for events of early life

is

well retained

and furnishes the

chief topics for conversation.

The gaps

are very often made good by extensive fabrications. Finally, as the result of the progressive impairment of memory, to which nothing new is ever added, there

memory

develops an increasing impoverishment of the store of ideas, with an extraordinary dearth and uniformity of the content
of thought.

and lack of sympathy are the prominent characteristics. The patients become apathetic; they fail to enter into the sorrows and joys of
In emotional
attitude, indifference

SENILE DEMENTIA

373

those about them, and do not grieve at the loss of friends. Self-interest, with the gratification of personal whims, precedes everything. They are no longer interested in their family or home. This may advance to genuine avarice, the

overwhelming even filial affection. The fundamental emotional tone is sometimes that of surly disfeeling of greed
satisfaction,

and

at others a

childish

happiness and an
irritability for short

exalted self-confidence.

There

may

be

are inconsiderate, arbitrary, dogmatic, periods. and offended at any opposition. The emotional states are

The patients

both superficial and transitory; extreme and tearful sympathy or silly happiness may be aroused on the slightest pretext

sexual feelings are frequently increased, impelling the patients to enter into improper sexual relations, especially with children ; to use
just as rapidly disappear.

and

The

obscene language, to dress in an attractive manner, plan marriages, and in extreme conditions to expose themselves.

The

conduct of the patients varies greatly.

Many remain

and contented, and, in spite of increasing decause no trouble and can be kept at home. Other mentia,
quiet, orderly,

an increasing restlessness: they abuse those about them at every opgrumble, quarrel, curse,
patients gradually develop
aggressive. Many to idulge in excesses, to masturbate, to wander patients begin away from home, to make foolish purchases and plans, to hoard all sorts of plunder, and ultimately get themselves into

portunity,

and often threaten and become

many

difficulties.

But nocturnal

restlessness is

most charac-

teristic.

It consists in getting out of

and

dishevelling the

bed, wandering about the house with a light, and rummaging chests and closets without evident purpose. During the day these patients are weary and drowsy and frequently fall to Patients are unable to sleep during conversation and meals.
care for themselves properly and are dirty about their clothing.

374

FORMS OF MENTAL DISEASE
In addition to the insomnia, there

Physical Symptoms.
is

and some anorexia.

usually a pronounced deterioration in the general physique The patients usually look older than

they really are, the musculature is reduced, and the strength below par. A fine tremor is characteristic of the senile, and

can be distinguished from the tremor of the paretic and the
irregularities in the separate there are a series of physical sympstrokes. Furthermore, toms corresponding to the cortical lesions; namely, headache,

alcoholic

by the numerous

vertigo,

convulsive seizures with transitory or permanent

aphasic symptoms, hemiansesthesias, hemianopsia, ptosis, hemiparesis of the muscles of the eye, tongue, or extremities.

The

pupils are sometimes small, or unequal, and react slugThe reflexes are usually increased, gishly or not at all.

seldom

diminished.

The

speech

is

often

indistinct.

Neuritic disturbances are frequent. Finally, evidences of arteriosclerosis are frequently observed.

In the severer grade of senile dementia there develops great clouding of consciousness and complete disorientation. These
patients apprehend what is said to them and respond briefly in a sensible manner, but they are wholly unable to grasp

what is taking place about them. They have no idea of where they are, address their associates by the names of friends long since dead, and even fail to recognize their relatives. They have very little memory for what occurs in their daily lives, and gradually lose even their remote knowledge. They cannot tell how old they are, or how many children they have. They say they are twenty-five years of
age, have

had twenty-five

children, the oldest of
still

which

is

twenty-five years, that they

pregnant. They undress at call the physician by their husbands' names.
easily distracted

menstruate, and are now midday, thinking it night, and

They are and cannot hold long to one thought.

SENILE DEMENTIA

375

The store of ideas is greatly impoverished and the same remarks are repeated over and over again. They occasionally indulge in a peculiar senseless rhyming and a half-singing repetition of words and syllables. Numerous changing fantastic delusions are present, both depressive and expansive, and often also hypochondriacal and nihilistic. They cannot speak, eat, or sleep; nothing has passed their bowels in weeks, and the liver has rotted away. They have leaned against a radiator and burned a hole in the
lungs which has caused the heart to cease beating. Their abdomens have been cut open and organs removed, or they will be buried alive. On the other hand, they may claim
that they possess much property, hold an important position, or are in communication with God. The delusions are apt to

be

embellished

with

numerous

fabrications.

Hallucina-

and hearing are frequently present. The emotional attitude varies. The patients are sometimes apprehensive and dejected, sometimes irritable, and at others, elated and happy, while rapid changes from one mood to another are common. In actions they display more or less restless activity, which is especially marked at night. They regularly tear and throw about their bedding, creep about the room, picking into the corners, destroying and smearing their clothing, or they laugh, sing, and run about in a silly manner. They are very untidy, and wholly incapable of caring for themselves. Insomnia is pronounced, and very
tions of sight
little

nourishment

is

taken.

In the group of cases of senile dementia called presbyophrenia, the patients, in spite of a marked disturbance of
the impressibility of
alertness, the coherence of thought,

memory, retain fairly well their mental and to a certain extent, also,

good judgment. Women predominate in this group, and chiefly robust individuals are affected. Usually the disease

376

FORMS OF MENTAL DISEASE

develops gradually, sometimes following more or less definite

prodromal symptoms which have been in existence for some weeks. It may appear as an episode during the course of
simple senile deterioration.

The patients are capable tion, and of comprehending

of entering into a long conversa-

in great

measure the occurrences

in their environment, but they utterly fail in obtaining

any

conception of their own condition or of their relation to the environment. They forget almost immediately what they

have been doing or what they have heard.
casional impression
is

Only an oc-

retained,

and

especially those ac-

companied by some
orientation
is

Place and, particularly, time feeling. disturbed. Patients cannot tell where they are

strangers as acquaintances ; regretting that they cannot just recall the name, but they are confident that they have seen them before. They know

or those about them.

They greet

neither the day nor the week. They make all sorts of contradictory statements as to their age, speak as if their parents were still living, and refer to their own infant children. The
store of

Their ability to reckon may be fairly well retained, as well as knowledge of the small affairs of daily life, like the price of articles of food, cooking
knowledge also
is

faulty.

receipts, etc., but all

beyond that is lost. They cannot recall and geographical facts, the name of the President, and, indeed, sometimes even the names and ages of their own
historical

children, but yet they
facts, as their

may

be able to recall a few remote
the playmates of their

own maiden name and

childhood.

The

patients do not appreciate these

marked

defects.

When quizzed, they will explain their inability to answer such
questions by the fact that they were never interested in such things, that women are not supposed to bother about such
matters, etc.

They usually make good the

lapses in their

SENILE DEMENTIA
recent memories

377

they were busy in the morning, had been out to call on their parents, other relatives were there, and they all drank some

by simple

fabrications;

such

as, that

Now they have come here to help with some work, but are soon going to return to their place of employment,
coffee.

where they are earning good wages. These patients rarely express delusions or have hallucinations.
Their judgment
their early
is fairly

well retained as far as
facts

it

involves

knowledge and
"
that ball
is

which are at their disposal.
is

" For instance, such senseless expressions as that the snow
black," or

square" cause them to smile, and

they become indignant if told that they steal or perjure themselves. On the other hand, the patients fail to recognize the

most absurd contradictions as regards the temporal relation of events, even when their attention is called to them. They will say that their parents are no older than they, that their daughter is only three years younger, though she was born more than ten years ago. In their conversation the patients are often energetic and loquacious, although they frequently
digress.

emotional attitude of the patients is usually that of happiness with an occasional brief show of peevishness or They exhibit an interest and readily familiarize irritability.

The

themselves with their environment and can appreciate a joke. In conduct they are, in general, orderly, and busy themselves
in one

way

or another.

restlessness.

Occasionally there is some nocturnal Symptoms of severe brain lesions, particularly
attacks, are rarely encountered.

paralysis

and apoplectic

This picture of presbyophrenia

a number of years. Again simple stupid dementia.
Senile Delirium.

it

may persist unchanged for may pass over into a state of
is

This form

characterized by

a more

acute onset

and a

short course with great clouding of conscious-

378

FORMS OF MENTAL DISEASE
j

active hallucinations,

and

delirious conduct.

It often

appears as an episode in the course of senile deterioration;
indeed, signs of beginning senile dementia usually precede the outbreak. Exciting causes are prominent; such as acute illnesses, mental shock, or injuries.

The patients rapidly develop many hallucinations of sight and hearing. They hear voices, threats, singing, see the devil, or crowds of men pressing upon them with knives. They are anxious and restless, claiming that they are in the
world below, surrounded by mighty powers, are bewitched and poisoned, the house is being flooded and huge boulders Disorientation is complete. The rolled about the room.
speech
is

irrelevant, incoherent,

and

flighty,

and

is

often

limited to unintelligible, disjointed words, or to a repetition There is usually great pressure of of senseless syllables.

speech.

The activity is greatly increased; they rattle doors and windows, shout for help, refuse food, resist, tear up the bedding, and crawl about the floor, etc. Insomnia is
extreme.

The

course of the delirium presents
less

many

fluctuations

and

sudden remissions, with more or
consciousness.
interval, or
it

The delirium may

complete return to clear reappear after a short

peevishness,

may pass over into a state of anxiety with which may persist, or in time entirely disappear.

In unfavorable cases the delirium becomes extreme, leading to collapse and death from exhaustion, injuries, or acute
febrile diseases.

Finally, there is a characteristic group of cases in senile dementia which has been called senile delusional insanity.

These cases develop gradually.
cent, irritable,

The

and suspicious. It are dominated by delusions ; that they believe that that they they are being robbed, are being ridiculed and insulted by

become retisoon becomes apparent
patients

SENILE DEMENTIA
their neighbors,
is

379

and are hindered in

being placed in their food.

that poison These delusions are ap;

their

work

parently scanty, somewhat incoherent, and are rarely elaborated, though they may remain unchanged a long time.
Hallucinations are often present, especially in deaf patients.

The

patients remain completely oriented. However, persons in the environment, who are involved in their delusions, may be mistaken for others. The emotional attitude usually

table

becomes indifferent, though occasionally the patients are irriand egotistical. In conduct they are orderly and tract-

able; they busy themselves

and only occasionally are

excited.

Diagnosis.

The

normal

senility,

to physiological changes such as the defect in the impressibility of
of the store of ideas,

common

memory, an impoverishment

an emo-

tional indifference, a paralysis of activity, and the development of stubborn unruliness, renders very difficult the
differentiation of the milder

forms of senile dementia.
is

wholly arbitrary. appearance of delusions and of excitement should leave no doubt as to the presence of a psychosis. The depressive states in senile dementia may be differentiated from melancholia by the dearth and the incoherence of the delusions and
the defective

certain

extent this

distinction

To a The

memory and emotional
It

dulness.
arteriosclerotic

The

differentiation of senile
is difficult.

dementia from

has already been indicated that focal insanity symptoms of themselves are not particularly characteristic of senile dementia, and point only to the fact that there is

an accompanying vascular prominent such symptoms

Therefore, the more the greater the role of are, arteriosclerotic changes. Inversely, a rapid and general decay of the mental activity, particularly a severe disorder
disease.

of

memory,

indicates senile dementia.

The same observawhich the dementia

tion holds true in syphilitic insanity, in

380

FORMS OF MENTAL DISEASE

never becomes very pronounced until after a long duration, while hallucinations and delusions are more prominent. The senile delirium, except for the underlying basis of
deterioration, does not differ

from the delirium encountered
is

in other psychoses.

wholly symptomatic. The condition of faulty nutrition needs careful watching in order to secure the ingestion of a sufficient amount of easily diTreatment.

The treatment

gested food.

The insomnia

of the senile is
first

most

intractable.

employ the simplest remeit, the time the patient awakes dies; as, warm nourishment at after the sleep of the early night, prolonged warm baths, and
In combating
one should
sufficiently

warm bed

clothing, together with,

if

necessary,

hot-water bottles.
cautiously.

Warm

packs should be employed most

Of the hypnotic remedies, alcohol is most useful. Paraldehyde, chloralamide, and somnos are at times also efficient. Occasionally small and repeated doses of nitroglycerin give excellent results. These patients, if kept at home, must be watched closely at night, and placed in rooms without lights and with guarded windows in order to prevent injuries to self and danger from fire to others. If the insomnia and restlessness become extreme, the prolonged warm
bath (see
p. 140)

may

be used.

Failing in this, one should

improvise a padded room or a bed with high padded sides. In the cases accompanied by great anxiety, opium (see p. 362)
is

indicated

and often brings the desired

relief.

IX.

MANIC-DEPRESSIVE INSANITY 1
the recurrence

MANIC-DEPRESSIVE insanity is characterized by
groups of mental symptoms throughout the dividual, not leading to mental deterioration.
of

life of the

in-

of

symptoms are

sufficiently

well defined

to

These groups be termed the
of the disease.

manic,

the depressive,

and

the

mixed phases

The chief symptoms usually appearing in the manic phase are: psychomotor excitement with pressure of activity, flight
of ideas,

distractibUity,

tional attitude.

In

the

and happy though unstable emodepressive phase we expect to find
absence
of

psychomotor

retardation,

spontaneous

activity,

dearth of ideas,

and depressed emotional attitude; white the the mixed phase consist of various combinations symptoms of of the symptoms characteristic of both the manic and depresEtiology.

sive phases.

Manic-depressive insanity

is

one of the most

prominent forms of mental disease, and comprises from, twelve to twenty per cent, of admissions to insane hospitals.

Of the

etiological factors, defective heredity is the

most im-

portant, occurring in from seventy to eighty per cent, of
Kirn, Die periodischen Psychosen, 1878 Mendel, Die Manie, eine Pick, Emmerich, Schmidt's Jahrbucher, CXC, 2 Monographic, 1881 Circulates Irresein, Eulenburgs Realencyclopsedie, 2. Auflage; Hoche, Ueber die leichteren Formen des periodischen Irreseins, 1897; Hecke, Zeitschrift fur praktische Aertze, 1898, 1 Pilcz, Die periodischen Geistesstorungen, 1901; Thalbitzer, Den manio-depressive Psykose, Stem;

1

;

;

;

mingssindsygdom, 1902;

Hoch, Ref. Hand. Med.
381

Soc., Vol. V, 120.

382
cases.

FORMS OF MENTAL DISEASE
The
relatives

have often suffered from the same form
is

of disease.

The

defective constitutional basis

often ap-

parent in individuals previous to the onset of the psychosis;

some are peculiar, some are abnormally bright, others are of an excitable disposition and subject to frequent and apparently causeless changes of mood, and still others are excessively shy and reserved; while a few are imbecile from birth.
Physical stigmata
in the disease

may also be present.

Women predominate
of the patients.

and represent about two-thirds

The

nal causes.

disease almost always appears independently of exterIn a few cases the appearance of the first
is

attack

coincident with the

first

menstruation.

The

first

and

subsequent may during succeeding periods of childbearing, but it is also a conspicuous fact that the attacks do not cease at the climacterium. In twothirds of the cases the first attack appears before twenty-five years of age, and in less than ten per cent, after the fortieth year, in

attacks

occur

both of which periods

women

The first attack may occur as early age, and as late as seventy years. The nature of manic-depressive insanity
nate.

greatly predomias ten years of

is still

obscure.

Several hypotheses have been formulated, but none are adequate. There are no demonstrable anatomical, pathological
lesions characteristic of this disease.

Apprehension of external impressions Symptomatology. in the manic states, with the exception of hypomania, is

more or less disturbed.

This disturbance

is

due largely to the

great distractibility of attention. The patients lose the ability to select and elaborate their impressions, because each striking sensory stimulus forces itself upon them so strongly

that

it

absorbs their entire attention.

Their attention

may

be held for a
it

is

holding objects before them, but distracted by something else. quickly Hence, the

moment by

MANIC-DEPRESSIVE INSANITY

383

environment is never fully apprehended, and the picture remains disconnected and incomplete, although there is no In the depressive serious disorder of the perceptive process.
forms
apprehension
especially
is is

more manifestly and extensively
this true in stupor.

disturbed;

Even

in the

lighter depressive states the patients are unable to elaborate

and comprehend
of the disease.

well their impressions. Consciousness is regularly disturbed in the severer forms

At the height

of

the manic excitement

the

Patients hazy impressions lead to disorientation. do not correctly understand where they are, mistake persons,
of relatives

and greet the physicians and nurses by the names
or neighbors.

This mistaking of persons sometimes arises from slight similarities of dress or facial expression, but at other times it seems to be due altogether to the capriciousness of the patients. In the less severe manic forms consciousness is very slightly disturbed. On the other hand, in

the depressive states of the disease consciousness clouded, particularly in the stuporous conditions.

is

more

Hallucinations are rare, except in the delirious form of the manic phase, and in the more marked stuporous depressive conditions, but even here they are neither a prominent

nor persistent feature. Furthermore, the hallucinations do not have the same sensory distinctness common to the sense deceptions of dementia prsecox. On the other hand,

numerous and varied

false sensations often

accompany the

pronounced hypochondriacal fears of the depressive patients. These are experienced all over the body. Patients claim
that they feel the food as

they
skin,

feel their

solving,

and

courses through the veins, that organs being consumed, that nerves are disthat little white worms are crawling under the
it

etc.

This

increased

sensitiveness

to

the

internal

processes of the

body stands out

in contrast to the loss of

384

FORMS OF MENTAL DISEASE
manic manic to hunger, and to

central sensitiveness to external impressions in the states, as seen in the remarkable insensibility of the

patients to extremes of heat
pain.

and

cold,

Memory
itself,

does not suffer

Especially in the depressive states the patients are often unable to recall even simple It takes them a very long time to solve a simple facts.

although patients over their store of ideas.

injury from the disease often temporarily lose control

much

problem or to

relate some experience. During the disease It has the impressibility of memory is impaired. process been shown by special tests that manic patients make more

than normal individuals in recalling to memory their perceptions. There is sometimes a tendency to fabricaerrors

and to depict grotesque experiences. Memory for events of the attack is usually somewhat indistinct, partions
ticularly

where there has been pronounced excitement or

profound stupor.
Delusions are often present in manic-depressive insanity. In the manic phases they are changeable and frequently

appear in the form of playful boasts and exaggerations. Where the consciousness is -somewhat clouded, the patients
tend to elaborate more permanent expansive and persecutory delusions, the latter being directed particularly against the family; also delusions of jealousy and poisoning. In the depressive states hypochondriacal ideas are most

prominent, and are often associated with delusions of persecution and of self-accusation. The depressive delusions

sometimes beome markedly
expressed
insight;

fantastic,

similar

to

those

by

pare tics.

Patients

usually

express

some

they appreciate having undergone a change, but are quite apt to attribute it to misfortune or abuse of they some sort, rather than to mental illness.

MANIC-DEPRESSIVE INSANITY

385

Disturbances of thought are prominent symptoms. In the manic states a definite line of thought cannot be followed

out; ideas pass abruptly from one subject to another, and the line of discourse is lost in a mass of detail. A short

question

may

of a host of details

be answered correctly, but with the addition and side remarks that have only a distant

It is impossible relation to the subject circumstantiality. for the patients to relate any event coherently without

frequent inquiries and suggestions on the part of the listener to recall him from his digressions. There is a lack of voluntary

guidance of the train of thought

;

hence there are abrupt

changes in the succession of ideas influenced

happen to come into the field of vision, up from the surroundings. On the whole, there is a multitude of ideas which are not well connected. There is no controlling goal idea. The association of ideas follows along accustomed tracks, especially those that play an
important part in daily expressions; such as bits of slang and common phrases. The resulting incoherence of thought Observation of gives rise to the so-called flight of ideas.
external objects
plete,

by objects that or by sounds caught

may seem
it is

to be very accurate

and com-

but in reality

superficial.

A

tracts the attention,

is

apprehended, and

striking object atstarts a train of

thought, but before this has proceeded far something else obtrudes upon the sensorium, and another is started. In

thought is delayed. Instead an acceleration of the train of ideas, there is only flightiness and an instability. There is an abundance of words, not
spite of appearances, genuine

of

of ideas.

Sometimes

in the depressive forms there

is

a

slight degree of flight of ideas.

As a counterpart
of

to flight of ideas,

we have

retardation

thought,

which regularly accompanies the depressive

phases of the disease, and also some of the manic-stuporous
2c

386
states

FORMS OF MENTAL DISEASE
and the forms
of

manic excitement

allied to

them.

Patients seem unable to marshal their ideas, and are often painfully aware of this. The individual ideas seem to develop
slowly and only after very strong stimuli. Hence, external impressions do not quickly and easily arouse a group of
associations, but the train of thought has to progress slowly

and requires an especial effort of the will. On the other hand, an idea once developed is not pushed aside by the appearance of new ideas, but it fades slowly and often sticks
with great persistency, especially if it arises in connection with some feeling. Thus there result great difficulty and
slowness of thought, monosyllabic answers to simple quesThis is apt to be regarded as tions, and a dearth of ideas. evidence of dementia, until close observation demonstrates
that there
is

no

real deterioration.

The emotional attitude in the manic forms shows more or There is a feeling of wellless elation and happiness. being with a tendency to joke and to make facetious remarks.
Irritability is Expressions of emotion are unrestrained. prominent, giving rise at times to outbursts of anger from trivial causes, but rapid changes in the emotional attitude

are

still

more

characteristic:

in the midst of joy patients of abuse

become

tearful,

and complain

and misfortune;

again, in spite of profound misery, they may burst out into boisterous laughter. These varying states appear and

disappear with the greatest rapidity.

Depression of spirits

sometimes appears for a few hours at a time during manic states. In the depressive states of the disease the emotional
regularly that of gloominess, despair, doubt, and anxiety. Patients complain particularly of the loss of in" " terest in things; they everything is the same to them," " are desolate and empty," they are dead, because they

attitude

is

have no feeling," " music does not sound natural," and

MANIC-DEPRESSIVE INSANITY
"

387

the crying of the children no longer creates sympathy." They feel as if they no longer belong to this world. One sometimes encounters moments when patients exhibit feeble

There are some cases of simple retardation in which there is no especial emotional tone. In the transition states and mixed
phases there is stupor with silent mirth, or restless mischievousness with anxiety. The disturbances found in the psychomotor sphere are prominent symptoms. In the manic states the increased
facility for

attempts at laughter and even brief gayety.

to pressure of activity.

the conveyance of stimuli into action gives rise Every sort of impulse leads to an

action, completely inhibiting all

or even
before

if

a volitional action

is

normal volitional impulses, begun, it is overwhelmed

accomplished. Furthermore, almost imperceptible impulses excite the greatest variety of movements, which are executed with unusual energy. In the mildest
half

manic states there appears a characteristic busyness and an excessive display of energy over trifles. If the disease is more severe, the actions become disconnected, and new
impulses intrude before any one object can be accomplished. In the severest excitement, the actions change as rapidly
as the ideas.

The

actions, however,

depend upon and bear

a definite relation to the ideas and emotions.
of the

The

intensity

motor excitement
largely

is

due to an increased
stimuli,

irritability

and depends
of

upon external

the removal

Unrestrained activity tends activity. to increase the excitement. The ready release of the motor
impulses perhaps accounts for the unusual absence of fatigue. In these conditions excitement may persist for weeks or

which reduces the

even months without any signs of exhaustion.
in the field of speech,

The psychomotor pressure of activity is prominent also and aids in the production of, flight of

388

FORMS OF MENTAL DISEASE

ideas. The easily aroused motor-speech dispositions have a stronger influence in directing the train of thought than

the ideas arising from purely intellective processes. Instead of a logical sequence of ideas, we find that motor coordinations determine their succession; thus, we encounter those associations common in the everyday life; such as,
set phrases, slang,

of pure
as,
is

and rhymes, and finally a predominance sound associations, when are heard such productions " Sam, jam, bang, slam, hell, shell, bells," etc. Silence

impossible. The patients prattle away and shout at the top of their voices, scream, declaim with many gestures and in a pompous manner, perhaps ending in unrestrained
laughter, or they sing, now softly, now slowly. lowing is a sample of the manic production:

The

fol-

" I was looking at you, the sweet voice, that does not want sweet soap. You always work Harvard, for the hardware store.

Here is the right hand, the hand that they shot off yesterday. The love of God don't win gray hairs. I don't care if I am nine-

my father taught me to love. Neatness of feet don't win but feet win the neatness of men. Run don't run west, but west runs east. I like west strawberries best. Rebels don't shoot For three years I got over seven dollars a month devils at night. and some old rags. Take your time and be not disobedient, be God's laws are all right, but grateful when judgment day comes. Royal Baking Powder is compressed yeast. Women should never chew gum. Women should never smoke. Women should mind their own business. Fish-hooks are between the American flag, You must pay for your own red, white, and blue, Fourth of July. Prudence. I am no tobacco chewer, I am no street walker, fiddler, I am vaccinated, but McKinley does not win. My father is a Democrat. He had no work for three years."
teen,
feet,

Such incoherence

is

not the outcome of an excessive

repletion of ideas, but results from an inability to give normal individual, at direction to the train of ideas.

A

MANIC-DEPRESSIVE INSANITY
times,

389
if

might give expression to a similar production

he

could utter a sequence of ideas as they came into his mind. In the disease picture this ideomotor excitability regularly
leads to the expression of every idea that presents itself. The letter- writing of manic patients shows with equal

Single phrases and sentences may be well started, but are soon resolved into a senseless enumeration of catch phrases, bits of slang, and
clearness the

same disturbance.

rhyme.

and bold, while underlining, overwriting, and punctuation marks predominate. The psychomotor field in the depressive form presents a retardation of activity, due to the slowness of conversion In the of sensory and ideational stimuli into impulses.

The

script is coarse

mildest degree this retardation appears as a deficiency in the power of resolution. Actions may not only be performed
slowly, but even after being started

may fail

of completion.

The

and talking, are and without energy. Unless extreme, performed very slowly the retardation may be overcome by an emotional excitement, such as impending danger or some unusual stimulus.
simplest movements, such as walking

In the severest forms the retardation leads to a complete
abolition of all voluntary movements, producing a condition of stupor, when the patients are unable to leave the bed or

attend to their physical needs. Retardation may vary considerably in the extent to

which
tivity.

it

influences the different spheres of voluntary acThe patients may perhaps be able to dress them-

selves

employ themselves without difficulty, but from any act that demands resolution. Some they shrink patients are so taciturn and monosyllabic that it is impossible to engage them in conversation, and although they
to

and

are able to count or read aloud as rapidly as ever, they will sit for hours with a letter in front of them, unable to finish

390
writing
it.

FORMS OF MENTAL DISEASE

Again there are patients who read rapidly, but line; and there are others who write long letters, but become speechless as soon as you address them. The symptoms enumerated above portray the disease
cannot write a
picture as a whole. As already indicated, these symptoms tend to arrange themselves into two large groups, representing the manic and the depressive phases of the disease,

and a third smaller group, the mixed phase.
individual cases
fail

Occasionally, to present sufficiently clear pictures to permit their definite assignment to any one of these phases, which condition, together with the occurrence of numerous
transition stages from one phase to another, emphasizes the fact that it is impossible to draw a distinct border
line

between the prominent phases of the

disease.

MANIC STATES
The manic
delirious mania.

states

comprise

hypomania, mania, and

Hypomania represents the mildest form of the manic " mania mitis," states, and has been variously designated " " folie raisonnante." or mitissima," and Consciousness, apprehension, and memory are undisturbed. The activity of the mind and of the attention is often increased; indeed, the patients may appear brighter and clearer minded than usual, because of their ability to grasp
but in reality they cannot make use of any valid comparisons. In the realm of ideation they show a moderate flight of ideas, which is more especially noticed in letters. They shift abruptly from one subject to another,
faint resemblances,

and are quite unable sion. They are very
being centered about

to bring a thought to a logical conclutalkative, the content of conversation commonplace affairs, their experiences

and

difficulties.

They

revel in

minute

details,

and often

MANIC-DEPRESSIVE INSANITY
distort the facts with exaggerations

391

and frequent misrepreis

sentations.

In the severer grades there

a striking lack

of coherence in the train of thought.

The patients are unable

to arrange logically a series of ideas without abrupt transiIn their writings and tions from one subject to another. rhymes they often develop a flight of ideas. Upon effort

they may be able, for short periods, to gain the mastery over their incoherent thoughts, as well as over their excessive
activity.

There

may

occur, for short periods,

more marked
Patients

excitement and dazedness.

Memory
tions

for recent events is not always correct.

in their conversation are easily carried

away with exaggera-

distortions, which arise in part from their keener perception and in part from accessory interpretations,

and

which never really come clearly into consciousness. Although there are no genuine delusions, yet there is a greatly exaggerated self-esteem. Patients boast of their own deeds and show a proportionate lack of appreciation for those of
others.

they lack insight into their condition. While they may admit a previous attack, they cannot regard their present state as anything but normal. They justify

Hence,

their actions in a
ible excuses.

most persistent way, and never lack plaus-

Moreover, they believe themselves misjudged

or falsely confined, as they never were

more healthy or

and

capable of work. Usually, in their estimation, the relatives friends, or those who have been instrumental in their

confinement, are the ones in need of treatment. As to the emotional attitude the patients are usually elated, happy, cheerful, and often exuberant. They derive great

and undertakings. Some patients develop a pronounced humorous vein and a tenpleasure from their associations

dency to see the funny side of things, to make facetious remarks, to invent nicknames, and to make sport of them-

392
selves

FORMS OF MENTAL DISEASE
and
others.

They

are jovial

tinctly selfish,

while their

own

desires

and friendly, but disand wishes prevail.

On

the other hand,

increased irritability

may

develop,

when the

patients become discontented, intolerant, and quarrelsome with their environment. They are apt to become inconsiderate, saucy, and rude, whenever any one

opposes them.
fits

Insignificant occasions

may
They

lead to violent
are completely

of anger

and even

aggressiveness.

under the control of sudden impressions and emotions, which quickly acquire an irresistible power over them.
Their general conduct bears the stamp of impulsiveness and rashness; hence, on account of the slight disturbance of intellect, their conduct is often regarded as unscrupulous.

The most
motor

striking

symptom

of all
feel

is

the increased psycho-

patients compelled to be doing something all the time. They must take part in whatever goes on about them. Since the sense of fatigue is diminactivity.

The

ished, they

do not

feel

selves until late at night
ing, bustling

the need for rest, so they busy themand are up again early in the morn-

about on all sorts of business. They take long devote much time to pleasure, begin a diary, write walks, many letters, undertake long journeys to renew old acquaint-

and do many other things which they never would have thought of before. They suddenly change their occuances,

pation, attempt journalism, write verse, purchase property, give away many presents, build castles in the air, and start

numerous undertakings that are beyond both their capital and physical strength. Their actual capacity for work, however, is much diminished. They lack perseverance, become negligent, and apply themselves only to that which is agreeable. In general demeanor it is obvious that the patients are self-conscious and attempt to attract attention. They
in

MANIC-DEPRESSIVE INSANITY

393

dress in a conspicuous manner, and adorn themselves with and cosmetics. Their handwriting is characteristically large and coarse, with a display of many exclamation
flowers

and interrogation marks and much underlining.

In the

presence of others they always press forward, seek to assert
themselves, talk a great deal, gesticulate, and boast. They are apt to be discourteous and offensive in manner. In
spite of deep

mourning they indulge

in boisterous pleasures.

In the presence of women they relate questionable tales. They make free with strangers and persons of high rank, as if they were old friends. Their tendency to indulge in
all sorts of

often begin to drink

is particularly prominent. They and smoke, remain out late at night, keep questionable company, frequent saloons, and eat ex-

extravagances

are particularly apt to show increased sexual desires, and to dress in a striking manner, to attend dances, to read trashy novels, and to
fall

cessively of rich foods.

Women

in love.

Not
this

result during such attacks.

infrequently, betrothals and pregnancies Patients show extraordinary

craftiness

in

peculiar

and

senseless

behavior.

All

attempts on the part of
bursts

relatives to control

often irritate the patient,

and

are vain, give rise to passionate out-

them

and even

The

aggressiveness. disease picture as seen in the individual cases varies

considerably. The milder the disease process, the greater the opportunity for the individual's characteristics to enter
into the

Personal peculiarities are particularly apt to show themselves in the emotional field.

symptom

picture.

While many patients remain amiable, tractable, and approachable, and are troublesome only because of their restlessness,

others are extremely disagreeable on account of
irritability,

their imperiousness,
activity.

and

reckless pressure of

394

FORMS OF MENTAL DISEASE

The number of hours of sleep is cut Physical Symptoms. short by late retiring and early rising, but the actual sleep
The appetite is regularly improved, and the The skin appears healthy, and the weight may movements are strong and elastic. The course in this form is usually uniform. Improvement is very gradual, and often accompanied by remissions. The duration is seldom less than several months, and sometimes lasts over a year. The disease may, however, last
is

profound.

increase.

for only a

few days.

This condition often follows mania.

Mania (Tobsucht). The border line between hypomania and the less severe forms of manic excitement is not always sharply defined. The onset of mania is almost
always sudden, following a short period of headache or malaise, although a few days of simple depression may precede the onset. The patients rapidly develop great psychomotor

a pronounced flight of ideas, clouding of consciousness, disorientation, and great impulsiveness. Consciousness is more or less clouded. This is seen in
restlessness, with

partial or complete disorientation.

Patients

know

the time

are, but they perceive only in a superficial way the events of the environment. They mistake those about them for old acquaintances. Sometimes they desig-

and where they

nate them as historical personages, as congressmen, public
officials,

or

well-known

millionnaires.

Apprehension

is
:

greatly interfered with

by the extraordinary

distractibility

sounds from the surroundings are caught up and woven
into their speech; an object held by the physician, or parts of his clothing, attract the attention and quickly lead the

thought in another direction, which

is

just as abruptly left

before the thought is half expressed, aiding in the production of a flight of ideas. Patients understand what is said
to them,

and are able

to give short, correct,

and pertinent

MANIC-DEPRESSIVE INSANITY
answers to questions.
lives

,

395

In this way facts concerning their

and occupation can be obtained by piecemeal. past Very often a patient shows some insight into his disordered condition, admitting that he is crazy and cannot control
himself.

In emotional attitude the patients are mostly happy and exuberant. Irritability, on the other hand, is very marked.
Trifling affairs, such as interference or contradictions,

may

lead to outbursts of passion with profane abuse, assaults, or destruction of the clothing or other objects. The rapid

changes of the emotions are still more characteristic. In the midst of joy they begin to lament and weep at the thought
of home, or because of abuse by their nurse. Abrupt changes to a condition of passion and rage are not infrequent.

In the psychomotor field there is great activity and excitement. Patients cannot sit or lie still; they run back and forth, dance about, turn handsprings, sing, shout, and prattle incessantly,

make all sorts of gestures, tear off clothing, down the hair, clap the hands, smear the person and pull room with grotesque designs, and ornament themselves in the most fantastic manner with clothing which has been
torn into
strips, as shown in Plate 11. Everything that they can lay their hands upon, from watch to shoes, is taken to

Bits of straw and pieces of stone, glass, and food are hoarded to plaster up a crevice in the wall or to pack a keyhole. In the absence of tobacco all sorts of material
pieces.

are used, leaves and bits of bread and even dried feces. They are especially apt to cram the nostrils and ears with foreign material, and to carry bits of glass, nails, stones, and
nutshells in

the mouth.

One

of

my

patients secreted a

an extracted tooth in his mouth for months. are quarrelsome and domineering, or mischievous They and playful. Because of great irritability, the most trivial

four-inch nail and

396
affairs

FORMS OF MENTAL DISEASE

may

lead to extreme violence

patients are

more apt
is

to

show

this

Female tendency than male.

and abuse.

manifest in shameless masturbations, exposure, and demands for intercourse, by indecent attitudes and insinuating remarks.

Sexual excitement

Some

of these cases of

mania may show

shorter period complete dazedness.

a longer or The patients then apfor

prehend their environment only in a fragmentary manner and are wholly disorientated. There is also great incoherence of speech, often combined with pronounced hallucinations

and delusions. The hallucinations are usually transitory. Sometimes faces are seen on the wall, shining objects appear on the ceiling, and flash-lights are seen as signals in the sky.
Noises are heard, floors creak, locomotives whistle, bells ring, and poisonous vapors are set free in their rooms at

Sometimes they complain of feeling electric shocks. Delusions are mostly expansive, seldom depressive. They are changeable and embellished by numerous fabrications.
night.

Patients claim that they are royal personages or generals, that they have supernatural strength, can produce planets,

and are related to God, etc. Many of these ideas are recognized by the patients as pure fabrications, are expressed with a laugh, and forgotten the next moment. The sleep is usually much disturbed, Physical Symptoms. and the patients may go weeks with almost no sleep. Nutrition suffers in spite of increased appetite,

but food

is

taken hurriedly and irregularly. There often occur attacks of syncope, and sometimes even convulsive attacks of a
hysteroid character. The heart's activity is usually increased and the pulse slowed, while the blood pressure is diminished. The urine is found to show a striking diminution of

The quantity

the phosphates, while calcium and magnesium are increased. of urine also is often increased. Pilcz has

PLATE

11.

Self-decorated manic patient.

MANIC-DEPRESSIVE INSANITY

397

shown that both in the manic and depressive phases there is excreted an abnormal amount of acetone, diacetic acid, indocan, and albumoses, which, however, bear no definite
relation to the intensity of the

symptoms.

The height of the disease is usually reached in the course of a week or two, and in some cases within a few days. The intensity of the symptoms is fairly uniform,
Course.

with

only

slight

fluctuations.

Occasionally

there

may

appear a sorrowful and depressed emotional condition, with disappearance of the motor activity, or even a transient stupor, indicating a transitory depressive state.

ine

improvement

is

very gradual; furthermore, for

Genusome time

after the return of comparative clearness, the patients are apt, under strain, to show a flight of ideas and some in-

creased activity.

Even after apparent complete recovery, reverses and misfortunes, and more often trying conditions, intoxication can cause a recurrence of the symptoms. The
duration varies considerably, from a few weeks and even days to many months, and sometimes two or three years. The
usual duration
several years.

many months. Some cases extend over The cases with many delusions and those
is

with exacerbations of excitement
Delirious Mania.
is

last longer.

This, the extreme of the

manic

states,

characterized

by pronounced dreamy

clouding of conscious-

ness , intense psychomotor activity, great incoherence of speech,

a marked

flight of ideas,

numerous hallucinations, and dream-

like delusions.
is a question if they to manic-depressive insanity. The onset is really belong sudden, following a few days of indisposition, uneasiness, and insomnia. The patients suddenly develop the greatest

These cases are very rare, and there

possible restlessness with

many
:

hallucinations,

which are

present in all of the sensory fields

they see beautiful sights,

398

FORMS OF MENTAL DISEASE

strange faces, and scenes of torture; hear distant music, ringing bells, cannonading, and the roar of wild animals.

Their food has a peculiar odor and taste, and small objects crawl on the skin. They see fire and hear the crackling
timbers.
fold,

Everything is changed. At the same time maniconfused, and dreamlike delusions appear, both of an
:

" chosen they are the have been elected Presidents, have wonderful power, ones," can create and destroy nations, possess millions ; they have

expansive and of a depressive nature

lost all friends, are to

be murdered, must enter

hell,

have

been taken to an immense height, and are
into the sea, etc.

now

to be cast

From

the

first
is

the consciousness

disorientation

almost complete.

oughly confused as to time, place, take their environment, and even their friends. Their speech is incoherent, abounding in sound associations,

greatly clouded, and The patients are thorand persons; they misis

rhymes, and numerous repetitions of single syllables and phrases, in which one can always detect many frag-

mentary references to objects in
tention usually

their environment.

At-

when a fragment

cannot be attracted except momentarily, of the desired response can be detected

in the incoherent speech.

Striking objects, such as a penny on the floor, will divert the attention and the train dropped of thought for a moment.

As

to the emotional attitude, the patients

show various

ecstatic joy

changes between extreme happiness and profound distress, and timidity, exuberance and apathy. Irri-

marked. In the psychomotor field the patients exhibit, from the beginning, signs of the most extreme excitement. They run about shouting and singing, disrobing, destroying everytability is very

thing within reach, and

they become

recklessly violent

MANIC-DEPRESSIVE INSANITY and
smear
themselves.

399

Occasionally they impulsively attempt suicide. At one moment they are praying, at the next cursing with the vilest language, or singing an obscene

and a minute
their
feet,

song; at one time they are insulting in speech and action, later are profuse in apologies and distasteThey chatter away, scream and stamp fully affectionate.

pound the window or door, race about at the greatest speed, mount the furniture and declaim in a loud voice with profuse and exaggerated gestures. The state of nutrition suffers Physical Symptoms. profoundly because of the small amount of food taken and
the excessive expenditure of energy. Occasionally there is a general muscular tremor. Sleep is greatly disturbed, and at the height of the disease is entirely lacking; the pulse
accelerated and the reflexes are exaggerated. Sometimes the conjunctivae are injected, and the vessels of the head and face distended. Occasionally there is profuse peris

spiration.

The height of the attack is quickly reached, within a few days or weeks, and the symptoms usually begin to abate at the third or fourth week. Brief intervals
Course.
of

composure often occur for a few minutes or a few hours, during which the consciousness remains clouded. The

improvement may be rapid, i.e. over night, but usually is gradual. For some time the patients, although clear, usually
retain residuals of their hallucinations, delusions, and peculiarities of conduct, and are especially inclined to be
irritable

and

distrustful.

But even these
few weeks.

signs

entirely
is

disappear in the course of a

There

rarely

any memory for the events of the acute stage of the psychosis. The disease may terminate fatally as the result of exhaustion, injuries, fat embolism of the lungs, or intercurrent infections.

400
It very often

FORMS OF MENTAL DISEASE

happens that following a manic attack the exhibit a low-spirited condition with more or less patients general weakness, which sometimes is regarded as a sort of
reaction, but

which

really represents a

transition into a

characteristic depressed phase.
easily,

and are unable

These patients tire very to apply themselves to either physical

or mental work, are despondent, worry about the future, are reticent, sluggish, and indecisive. These symptoms

gradually disappear with the increase of weight. In some instances, where the condition is more severe, there may

remain a permanent lack of judgment and emotional irritability, and also restlessness.

insight,

some

DEPRESSIVE STATES

The depressive states comprise simple retardation and the delusional form. The mildest form of the depressive states is characterized by the presence of simple retardation unaccompanied by
any hallucinations or
simple retardation.
delusions,

and

is,

therefore,

termed

The onset

is

which follow acute

generally gradual, except in a few cases illness or mental shock. There appears

gradually a sort of mental sluggishness: mental processes

become retarded, thought is difficult, and patients find difficulty in coming to a decision, in forming sentences, and in It is hard finding words with which to express themselves. in reading or ordinary confor them to follow the thought versation. The process of association of ideas is remarkably
retarded; the patients do not talk, because they have nothing to say; there is a dearth of ideas and a poverty of thought.

Familiar facts are no longer at their command, and to remember the most commonplace things.

it is

hard

In spite of this great slowness of apprehension and thought,

MANIC-DEPRESSIVE INSANITY
consciousness and orientation are well retained.
dull

401

Patients

appear sluggish, and explain that they really feel tired and exhausted. They sit about as if benumbed, with folded hands and bowed head, exhibiting no initiative and What is said is uttered rarely uttering a word voluntarily.

and

in

low,

inexpressive tones.

Customary

actions,

such as

walking, dressing, and eating, are performed very slowly, When started for a walk, they as if under constraint.
halt at the

doorway or at the

first

turning-point, undecided

which way to go.

Their usual duties loom before them as

huge tasks, because they lack strength to overcome the retardation, and anything new appears unsurmountable. Sometimes they become bedridden. Because of this extreme retardation, the patients rarely commit suicide, although they often express the desire to
suicide are
die.

Attempts at
dis-

more to be feared when the retardation has and while the despondency still persists. appeared,
In the emotional attitude there
is

a uniform depression.
life.

The

patient sees only the

dark side of

the future are alike, full of Life has lost its charm; they are unsuited to their environ-

The past and unhappiness and misfortune.

ment, are a failure in their profession, have lost religious faith, and live from day to day in gloomy submission to
their fate.

Everything
life

is

spoiled for them;

they take no

pleasure in

and do not care to

live longer.

They are
anxious,

ill-humored, gloomy, shy, sometimes

pettish or

and sometimes irritable and sullen. They fear business reverses and begin to economize, even denying themselves and their families the necessaries of life. Sometimes numerous compulsive ideas appear. Patients
compelled, against their will, to ponder over certain things, and to busy themselves with depicting unpleasant scenes. Others worry themselves over the thoughts of how
feel

SB

402

FORMS OF MENTAL DISEASE

they might be martyred or torn limb from limb. Even compulsions to act arise, such as to commit injury or to
set fire.

frequently present, the patients appreciating that a change has come over them. This very often is
Insight
is

characteristically expressed as a feeling of inadequacy.

The

"
patients say:

I

am

not

sick, I

am

only lacking a will of
"
I

my

own."

"

I can't pull myself together."

have no

energy, I can't get hold of myself."

"

I feel all

I can't make up my mind to do anything." recurring sadness is ascribed to external influences, such

gone and Sometimes the
as,

unpleasant experiences, changes in the environment, etc. The condition of retardation may, at some time during
the course of the psychosis, become so pronounced as to produce a condition of stupor. Patients then lie abed perfectly dumb, unable to comprehend their surroundings, or
to understand even simple questions.

There

is

no particular

emotional change to be noted, except occasionally when a look of anxiety or perplexity flits across the countenance. Voluntarily, the patients almost never speak. If able to answer questions, their responses are exceedingly slow-

They

sit

helplessly before their meals, allowing themselves

to be fed

by spoon, and holding

pressed into their hands. care for themselves, but are not filthy. This condition of stupor tends to disappear rapidly, and leaves no memory
of the events of the period.

firmly whatever may be These patients are unable to

variations.

Simple retardation runs a rather uniform course, with few The improvement is gradual, and the dura-

tion varies from a few

months

to over a year.

A

second group of depressive cases has been termed the

delusional form, which is characterized varied depreciatory delusions, especially

by
of

the presence of

self-accusation

MANIC-DEPRESSIVE INSANITY
and
of

403
evidences

a hypochondriacal nature, in addition
onset of this

to the

of retardation.

The

form

is

usually subacute, following a

and occasionally even a short period of exhilaration and buoyancy of spirits; a few cases appear after an acute illness or mental shock. The patients become profoundly despondent, and indulge
period of indisposition,

They feel that they have been great sinners, have neglected their duties and made many enemies, have never done anything right, and their whole life has been one long series of mistakes. They accuse
in all sorts of self-accusations.

themselves of bringing misfortune on others or of causing some great calamity. They claim that they are devoid of They feel that they are feeling and sympathy for others. fear arrest and imprisonment, they must being watched, die, are to be poisoned or shot. Others hold them in derision, laugh, and jeer at them. Their families are incriminated by their misdeeds, and are suffering imprisonment. They have lost everything, and will be driven into the street with their families, to wander about in utter misery. Hypochondriacal delusions are prominent and are usually associated with numerous false bodily sensations: their
health
is

ruined as the result of masturbation;

they are

succumbing to some malignant disease, and their organs are wasting away; cloudy urine signifies profound disease of the kidneys; they can never recover, and their body and face are altered. Female patients complain of being pregand often accuse themselves of immorality and masnant,
turbation.

These various delusions often become absurd and fanis that everything about them not their own; their friends and relatives have disappeared forever; they do not belong to

tastic.

A common
their

delusion
is

is

altered:

home

404

FORMS OF MENTAL DISEASE
but a skeleton

this world; they themselves are changed, are

and cannot die. Though life, they cannot live struck on the head or pierced in the heart, they would still live on. Their heart has ceased to beat ; their stomach and
without
intestines are entirely gone; there are

no

feces

;

they are
is

full
all

to the

throat with
;

decomposing food; their skin
occasionally

dried

up

their bones are softening, etc.

Hallucinations

are

associated

with

this

are heard, disagreeable condition, odors permeate the room, terrible apparitions appear at night, and fearful scenes are depicted.

when groans and moans

The
what

consciousness

is

for the

patients are usually oriented,

most part unclouded, and the and comprehend correctly

transpires in their environment, although occasionally they develop some delusional ideas in reference to the home or institution and the persons around them. They under-

stand questions and answer coherently, but the content of thought and speech shows a constant tendency to revert
to their depressive delusions. Thought is retarded, as shown in their attempts to write letters or to solve a problem.
Insight into the condition
is

very often present, yet while

admitting recovery from previous similar attacks, they declare that their present condition is so much worse that they can never recover. Some of these patients go to an institution of their

own

accord.

The

emotional attitude

is

uni-

formly one of depression. The patients are dej ected, gloomy, and perplexed, and lament for hours in monotonous tones.

They say little to those about them, but sit staring into space and paying very little attention to their environment. It, however, becomes evident during the visits of friends and
relatives that they are not only not apathetic,

but capable of
is

showing considerable feeling.
Psychomotor retardation of thought and action
evident

MANIC-DEPRESSIVE INSANITY
in their dearth of ideas, their silence,

405

and slow and hesitating replies to questions, their sluggish and languid movements, their lack of independent activity and inability to
apply themselves to mental work. Some patients at times exhibit anxious restlessness, pacing up and down the room, swaying the body or rocking uneasily in a chair, picking at
the clothing or rubbing some part of the body. attempts are not infrequent.
Suicidal

Stuporous

states

may

also develop in this delusional type

patients then develop a condition of befogged consciousness, in which almost no external impressions are apprehended and consciousness is domiof depressive cases.

The

nated by numerous variegated and incoherent delusions and hallucinations. Everything appears changed in the most fantastic manner; the whole world is being consumed by fire or congealed into ice. They themselves are removed from everybody, have been taken up into a cloud and carried off to the farthest point of the universe, and left
to be shoved off into space, where they will keep falling forever, or they are crowded into a narrow

there alone.

They are

grave from which they can never escape. The walls of the room are closing in upon them, and passing troops have arrived to attend their execution. Crowds jeer at them;

they are made to wear a crown of thorns, or are turned loose to run naked in the street. Everything about them has a

most mysterious aspect; they are in the midst of historical personages, and are made to do penance for the whole world. They have been transformed in a most horrible manner,
are of a different sex, are swollen to the size of a cask, have two heads, the body of a serpent, and the feet of an elephant. While in this dreamy state their retardation is shown by
their inability to speak, to feed themselves, or to care for themselves in any way. They do not show active feelings,

406

FORMS OF MENTAL DISEASE
stupidly in bed, are inaccessible and indifferent. occasional anxious expression, the resistance to passive
lie

but

An

movements, peculiar postures, and unexpected, impulsive attempts at suicide betray their anxiety and fear. Sometimes a few words or sentences are uttered very slowly and in low tones. These stuporous states disappear gradually, but even after consciousness has become clear, a few
hallucinations time.

and

delusions

usually

persist

for

some

of persecution

There are a few cases which present coherent delusions accompanied by many hallucinations with The hallucinations play a rather imclear consciousness.

portant part and persist for a long time, reminding one very much of acute alcoholic hallucinosis, save for the

psychomotor retardation. The patients complain of numbPhysical Symptoms.
ness in the head, ringing in the ears, dizziness, palpitation, chilliness in the neck, heaviness in the limbs, and of a feeling as if there was a weight upon the chest. The appetite is
poor, the tongue coated, and the bowels constipated. There usually a strong aversion to food, and it often requires considerable urging to administer sufficient nourishment.
sleep

is

The The and

disturbed by anxious dreams. facial expression and the general attitude are sleepy languid, the speech low, the eyes lustreless, the skin
is

much broken and

The body and cardiac activity Respiration weight always are weakened and slower, and blood pressure is increased, while the pulse is slow. The quantity of urine is diminished as well as the excretion of urea, phosphoric acid, and magnesia. The height of the disturbance is reached in a few weeks and runs a shorter course than the manic
sallow and without its accustomed firmness.
sinks.
states.

MANIC-DEPRESSIVE INSANITY

407

MIXED STATES 1
simultaneously varying combinations of some of the fundamental symptoms character-

In

these

states

there

occur

manic and depressive phases of the disease. The mixed states are most clearly seen during the transition periods when patients pass from a manic to a depressive phase or vice versa. At these times all the symptoms of one phase do not disappear simultaneously, so that symptoms
istic of both the

of the depressive phase develop before all of the

symptoms

of the

manic disappear.
flight of

manic

For instance, the characteristic ideas may have given way to typical retardastill

tion of thought, while there

remains emotional elation
this

and pressure

of activity.

A

few days farther along in

transition period, we find that there still is some elation, but retardation of activity has also developed. Later still,

and the

elation has given way to depression, and we have the In another case typical picture of the depressive phase.

during this transition period, the emotional elation may be the first symptom to subside and pass into despondency, while there still remain pressure of activity and flight of
ideas.

In a few days the

flight of ideas also
is still

has gone over

into retardation of thought, while there
of activity.

some pressure

Farther along, we find the pressure of activity replaced by retardation and the typical depressive picture. All together there have thus far been recognized six chief
types of mixed states.

mania, in which a depressed emotional state the usual elation. These are the cases of pronounced replaces manic excitement in which the patients exhibit a more or
(1)

Irascible

less
1

constant irritability; they heap abuse upon the environWeygandt, Ueber die Mischzustaende des manisch-depressiven
Habilitationsschrift, 1899.
Irre-

seins.

408

FORMS OF MENTAL DISEASE

ment, and become passionately angry and even aggressive upon the slightest provocation. If the excitement is not
quite so pronounced, there is produced the picture of the grumbling mania, in which the patients show a feeling of

somewhat increased

self-confidence,

but without

elation.

They

are dissatisfied, intolerant, perhaps a little anxious, have some fault to find with everything, always feel that they are mistreated, are served poor food, and have to sleep on

a wretched bed.

They have a

facility for offending

and

vexing others, and for instigating trouble for every one about them. Each day they have a new complaint, and become The fundamental manic irritable if they are not heeded.

symptoms
instability,
(2)

are seen in the moderate flight of ideas, the great

and

restlessness.

Depressive excitement comprises those depressive cases in which the restlessness is out of all proportion to the intensity of their emotional despondency. These pa-

but always about the same thing they torment themselves and their environment by the same old
tients talk incessantly,
;

complaints ; they are forever expressing the same delusional ideas, mostly of a hypochondriacal nature and usually in

They complain that they have been have been poisoned, can never recover, and are mistreated, going to die, but at the same time they are not especially
anxious or sad, and they are able to apply themselves without fatigue. They may even, for short periods, make humor-

the same phraseology.

ous or sarcastic remarks, and show some
aggressiveness.

irritability

and

Unproductive mania is the manic state with dearth This form is often encountered. The patients are very slow and inaccurate in perceiving. One often has to repeat a question several times before they understand it. They
(3)

of ideas.

don't pay attention, give

many

false

and evasive answers.

MANIC-DEPRESSIVE INSANITY

409

give one the impression that they are weak-minded, but later they prove themselves to be quite intellectual. This condition of unproductive mania fluctuates considera-

They

bly; at one time the patients

may

temporarily give ready

answers, while at another

it is

impossible to get anything

out of them.

one of elation, happiness, and exuberance; they laugh readily and without sufficient cause and make fun over every little thing. Their speech is inattitude
is

The emotional

coherent and the content limited.

They speak slowly and

do not have much to say; indeed, if left to themselves, they remain speechless for long periods. It is characteristic of the thinking difficulty to be more intense at the beginning
of an interview, but as the conversation is prolonged, the patients gradually develop considerable pressue of speech.

There

is

always present an increased emotional

irritability.

The

pressure of activity is usually confined to grimacing, occasional dancing around, changing the clothing, and fussing with the hair, but the patients never show the restless busy-

ness so characteristic of mania.

Many

of these patients

ordinarily conduct themselves so well and quietly that a superficial examination fails to reveal any excitement.

Nevertheless, they are in an elated frame of mind, at times showing irritability; they are tractable or rude, and often

break out in boisterous laughter. Other patients are inactive and sit around, but upon the slightest provocation
they laugh uproariously,
or, for no apparent reason, become are incapable of any orderly employment, but saucy. They are rather given to all sorts of mischievous tricks, stealing

and hoarding a lot of things, tearing up papers and clothing and tying knots in them, plugging up keyholes, and pasting paper designs all over the walls. Sometimes they suddenly burst out in great anger. Also, they may show

410

FORMS OF MENTAL DISEASE
and

transient periods of genuine mania with flight of ideas pronounced pressure of activity.
(4)

Manic stupor

is

the depressive state in which emo-

tional elation takes the place of the usual despondency.

The

patients are quite unapproachable; they do not bother themselves about their environment, will not answer questions, laugh without apparent cause, lie quietly in bed,

sometimes

all rolled

up

in the clothing, or dress

them up

in

a fantastic manner, but all of this is done without evidence of restlessness or emotional agitation. Sometimes a few
changeable
delusions
are expressed.

They
is

are

usually

well oriented.

Occasionally catalepsy

present.

In the

midst of this stupor the patients suddenly develop great activity, rush about, disrobe, tear their clothing, destroy

smear their food, sing and talk loudly and freely, often making bright and striking remarks, and then after a few hours as quickly return to the previous state. At other times one finds them quiet, perfectly clear and intellifurniture,

gent in conversation, but this

only for short periods. Many patients pace about in measured steps, never speak except to make an occasional witty remark, or rub up against the doctor in an erotic manner, and laugh. These patients
is

often have a good memory for what occurs, but they are wholly unable to explain their peculiar conduct. In some
cases the facial expression
is is

fixed

and

staring, in others it

more cheerful, happy, and amorous. Manic stupor often develops for a short time in a pronounced manic state, but it more frequently represents a transition state between a depressive stupor and a manic
state.

Depression with a Flight of Ideas. are easily aroused when they can cases
(5)

These depressive

show a

facility of

thought.

They read a good

deal,

show

interest in

and com-

MANIC-DEPRESSIVE INSANITY

411

prehend their environment, and, indeed, even evince some curiosity, in spite of the fact that they are retarded in their general attitude, are almost mute, and are despondent. These patients tell us as soon as they begin to talk again that they could not control their thoughts, that a whole
host of things would come into their minds which they had never thought of before. It seems, therefore, that there really exists a flight of ideas which, however, is not apparent
to others because of the retardation of the
articulation.

movements

of

Some

of these patients cannot express

them-

but can write, and often astonish one with numerous productions, containing delusional ideas of persecution and fear.
selves orally,

their

the depressive state with flight of ideas and emotional elation. These patients are happy,
(6)

Finally there

is

sometimes somewhat

are distractible, prone to witty remarks, and are easily aroused during conversation to a flight of ideas and at times even sound associations,
irritable,

but in general their demeanor is quiet. They lie quietly in bed, and now and then interpolate a remark or laugh
loudly.

Nevertheless there seems to exist an inner tension,

because the patients can suddenly become very violent. The mixed states occur most frequently in the transition
periods from manic to depressive states and vice versa. Indeed, it is only by the history of their development and their
transition into the well-known phases of the disease that we are able to recognize them as mixed phases and as a

type of manic-depressive insanity.

This observation

is

of

which mixed states almost wholly replace the typical manic and depressive phases. In such cases the recognition of the disease,
especial importance in those cases in

particularly in

the

first

attack,

is

extremely

difficult, if

not impossible.

412
Course.

FORMS OF MENTAL DISEASE
The course
of

manic-depressive insanity is marked by a recurrence of attacks separated by lucid intervals. With but very few exceptions, attacks recur throughout
the
life

of the individual, appearing with greater frequency

between the ages of eighteen to thirty and forty to fifty. In five per cent, of cases the attacks from the first pass directly from one phase into another, sometimes with such " " has been
alternating insanity apregularity that the name to them, or if short intervals of lucidity have intervened, plied " If only one or two attacks occur during circular insanity."

the

life

of

an

individual, the separate attacks are in

no

way
It

essentially different

from those recurring frequently.

seldom happens that all are of the same type; at some time or other a depressive attack is sure to appear. On the other hand, one patient during life may suffer from all possible
forms, from hypomania to profound stupor. The first attack in sixty per cent, of the cases
is

depressive.

This is especially true in women, and when the disease develops early in life. The first depressive attack usually runs a mild course, and in about fifty per cent, of the cases
followed immediately by a lucid interval. In the other fifty per cent, of the cases it is immediately followed by a manic attack, which in turn is followed by a lucid interval.
is

A

almost always followed by a lucid If the first attack is interval, seldom by a depressive attack. of the succeeding attacks are manic. manic, the majority
first

manic attack

is

several depressive attacks may recur before a attack appears; in other words, the occurrence of manic several attacks of one type to the exclusion of other types
Similarly,

indicates that the greater number of attacks throughout Later in the course of life will be of the same character.

be a regular alternation between manic and depressive attacks. After a long duration of
the disease there

may

MANIC-DEPRESSIVE INSANITY
the disease there
is

413

more apt

to be a regular alternation

from one type to the other, if the early attacks have been mostly of one type. The mixed forms usually do not appear until after two or more manic or depressive
attacks.

The duration of the individual attack may vary from a few days to five years, but the usual duration is from six to twelve months. The depressive attacks average longer. The first attacks rarely last longer than a few months. In
the circular type of the disease
alternates
it

has been observed that

simple retardation, hypomania usually while severe manic states are followed by deep stupor, and again, when delusions and hallucinations occur in the manic
states,

with

they are usually also present in the depressive
lucid intervals

states.

vary considerably in length, from a few days or weeks to many years, and stand in no definite
relation to the duration of the attacks.

The

They

however, to be longer at the beginning and attacks recur, until finally they may disappear altogether, the attacks then passing directly from one into another.

are apt, shorter as the

At the beginning

of the disease the intervals are usually

of at least one or

more

years' duration.

Sometimes the

intervals are of such a definite duration that the patients

know
to

The intervals tend just when to expect the attacks. become shorter during the climacterium and to lengthen out again later. Sometimes, especially in young females,
the disease begins with a series of several short attacks with brief intervals, which are then followed by a prolonged interval of several years.

In the small group of cases in which from the beginning the attacks succeed each other without
lucid intervals, the type of the attack
is

hypomania and simple retardation.

usually light, mostly Sometimes, even after

414

FORMS OF MENTAL DISEASE

a long series of such recurring attacks, there

may appear a

long lucid interval. During the intervals the patients are perfectly lucid, except in a few cases where the attacks are long, frequent,

and

are able to reenter the family, to employ themselves profitably, and to return to their profession.
severe.

They

The few who do not thoroughly recover are also usually able to return home, but are apt to show some restraint,
lack of independence, a tendency to be morose, an unusual susceptibility to fatigue, some sleepiness, and a diminished

capacity for work, or they may be irritable, quarrelsome, markedly egotistical, or unstable and easily excitable.

During the interval some of the patients
thorough appreciation of their disease.
"

fail

to

show a
admit

They

will

excited and nervous/' but attribute that they have been it to some family trouble or confinement.
It

tients

very often happens that during the intervals the pamay suddenly develop short periods of moderate

exhilaration, flightiness, irritability,

and unusual

activity,

or on the other hand, they may be unnaturally apprehensive,

and indifferent. These and without the history of symptoms disappear abruptly, other attacks might not be recognized as disease sympsuspicious,

despondent,

inactive,

toms.

The

transition

vice versa, is

from a manic to a depressive phase, and usually gradual, though it may be sudden,

often occurring during the night. In this transition the stages of alteration are usually quite perceptible. At first the countenance of the depressed patient becomes more

illuminated and the eyes appear brighter and the skin firmer

and more
dom.

elastic.

The

patient
first

interest in the surroundings,

His activity, at

is more affable, shows more and expresses a desire for freeincreasing slowly, now becomes

MANIC-DEPRESSIVE INSANITY
prominent;
better in his

415
felt

he

is

busy

all

the time,

is

happy, never

From this time life, and everything pleases. the manic state becomes quite evident. The manic patient
at
first
is

he

gradually loses weight, the pressure of activity abates, calmer and more in earnest, his many schemes recede

to the background

and then

entirely disappear.
is

Soon

his

movements become
less,

languid, he himself

seclusive, talks

and misonly occasionally mentioning His countenance loses its freshness, and at last fortunes. we have a typical depressive state.
his ill-feelings

usually little difficulty in recognizing the psychosis, where there has been a previous attack; yet the occurrence of more than one attack is by no means pathognomic of manic-depressive insanity, as it
Diagnosis.
is

There

may happen

in

dementia prsecox, especially in the catatonic

form, in paresis, melancholia, and in amentia. It is difficult to distinguish between the mildest forms
of manic-depressive
peculiarities

insanity

and

certain morbid personal
chiefly as a

which manifest themselves

more

or less regular vacillation of the emotional state.
depressive periods of ill-humor

The manicon the one hand, and of impetuous exhilaration on the other, are sometimes mistaken as simple whims and ascribed to all sorts of deleterious
influences, or

neurasthenia, and hypochondriasis,

they are apt to be designated as hysteria , since it is only in the
ill.

depressive states that the patients are considered

These

same patients themselves, however, often have insight into their periods of excitement and dread their approach. Usually the true nature of the disease is disclosed

by the

transi-

tion from one phase to another, and by the periodic recurrence of different phases. The simple lack of decision the inability of the depressive patients to

come

to a conclusion

is

so

characteristic that

it

alone often suffices in making the diag-

416
nosis.

FORMS OF MENTAL DISEASE

These border-line cases are numerous, and are often encountered in sanitaria. In the mild forms of the manic states, when one sees the
patient in the
patient's
first
life, it is

is without a history of the often difficult to distinguish the patients

attack and

from some normal individuals.
chiefly
is

The

distinction depends

ity

upon the fact that the increased busyness and activnot uniform, but shows variations. In the forms of
mania there are also noticeable aggravations and regular transitions into opposite moods.

constitutional

of the condition

Such

patients, because of their frequent conflicts with their

environment and the law, are usually considered swindlers and vagabonds, or are regarded as morally insane. In addition to the vacillations, the clinical picture also shows an attitude of overconfidence, an irritability, a lack of plan
in their excessive busyness, an excessive emotional irritability,

and a lack of criminal tendencies. The differentiation of the disease from the exhaustion psychoses and from the excited stages of the catatonic and
hebephrenic forms of dementia prsecox will be found fully detailed in the differential diagnosis of those diseases.

The manic forms

ment by the exuberant emotional
bility.

are differentiated from hysterical excitethe presence of the flight of ideas, pressure of activity,

The

hysterical

and the great distractiexcitement comes in the form of
state,

brief separate attacks

with definite outbursts of temper.

Hysterical excitement usually subsides quickly pletely after a very short duration.
It is

and com-

simple retardation from the initial period of depression in dementia pmcox. In the manic-depressive patients the psychomotor retardation, with slowness of movement, low tone of voice, difficulty
difficult to distinguish

more

of thought with sparsity of ideas, slowness of application

MANIC-DEPRESSIVE INSANITY
of attention,

417

and

slight clouding of consciousness, stands out

freedom of moveand to the clearness of consciousness ments and thought, in dementia prsecox. Rapid appearance of senseless delusions and numerous hallucinations without clouding of
in contrast to the absence of retardation,

consciousness speak for dementia praecox. The differentiation of the depressive states from dementia
paralytica

and melancholia have been discussed under these

psychoses.

Acquired neurasthenia is sufficiently differentiated from the depressed forms under that disease. The unproductive mania is often mistaken for imbecility

with excitement, but can be distinguished by the evidences of flight of ideas and the manic demeanor of the
patients with only moderate restlessness. Manic stupor sometimes must be differentiated from
catatonia.
If,
it

in

manic stupor, the patients
in

struggle, the

cause for

lies

almost always leads to abuse and violence.

the irritable, fretful disposition which Again, the

patients pay more attention to their environment, and are influenced in their actions by circumstances, in contradistinction to the stupid or wilful indifference of the catatonic.

Furthermore, the manic-stuporous patient displays a poverty of thought and not a stereotyped and senseless speech
production.

The movements of the catatonic are apt to be planless, impulsive, and with a uniform pressure of movement, while in stuporous mania they are purposeful, playful, and adapted to the environment.
in

The prognosis of the disease is unfavorable Prognosis. view of the certainty of recurrence of the attacks throughout the life of the individual. It is favorable for recovery
from the individual attacks, except in five per cent, of cases, which from the onset pass directly from one attack into anSa

418
other.

FORMS OF MENTAL DISEASE

While, with this exception, there are almost certain be other attacks and recoveries, the frequency of their to
recurrence and the duration of the lucid intervals
uncertain.
is

wholly

At present we have no means

of judging just

will be. In general it may be said, that it is safe to predict frequent recurrence of however, attacks with short intervals where the psychosis manifests itself early and without external cause. On the other hand,
if

what the future course

the

first

attack occurs late and following some external

cause, such as childbirth, there probably will be but few If pronounced mixed states predominate, the attacks.
If the onset is predisease will probably be more severe. vious to the period of involution, one should expect a recur-

rence during the climacterium. Mental deterioration occurs in only a few cases, where the attacks appear during the period of development and are
long,

frequent,

and

severe.

Even

these

patients in the

and retain a very good memory. They simply show some indifference, irritability, an increased susceptibility to alcohol, and slight
intervals are

conscious, well oriented,

There are a few cases that have manic attacks, lasting even ten years and more, very long which have been designated chronic mania. This condition is not one of dementia, but one in which there are
deficiency in judgment.

incomplete remissions. If observed carefully, these cases usually present not only manic states of varying intensity, but also evidences of depressive and mixed states. Furthermore,
it is

usually found that even in the lucid intervals the

patients have always been somewhat unstable, freakish, irritable, or have been schemers and incapable of any consistent

and productive employment.
constitutional

These cases are better termed

mania.

There

is

a corresponding series of transitions from the

MANIC-DEPRESSIVE INSANITY

419

depressive states. There are manic cases which in the intervals are shy, low spirited, and slow to make up their minds.

This defective constitution
individuals

is

more

characteristic in those

who suffer from periodic depressive states. there are cases in which the separate attacks of Finally periodical ill-humor present themselves without sharp
differentiation,

and are simple aggravations of a constitutional depression. Arteriosclerosis, or marked senile changes,
developing during the course of manic-depressive insanity, usually lead to states of dementia which obliterate the original mental picture.

Treatment.

The

disease, being deeply rooted in the per-

sonality of the individual, offers little chance to eradicate

the underlying causes. Individuals who seem to be predisposed to the disease certainly derive benefit from leading a careful life under favorable conditions and abstaining
absolutely from the use of alcohol.

Such persons should

not marry.
Individuals suffering from frequently and regularly recurring attacks can sometimes ward off an approaching

attack by the use of large doses of the bromides, even up to three hundred and sixty grains a day for a few days before the anticipated attack. Atropia, hypodermically, or bella-

donna

in the

form

of the extract in full doses, is highly recom-

mended for the same purpose. In those cases in which the attacks tend to develop during pregnancy or puerperium, artificial abortion has occasionally been performed for the
purpose of either warding off the attack or cutting it short. Kraepelin himself has not derived much benefit from this
procedure, but finds that, in spite of abortion, the disease recurs and runs its regular course. In all such cases measures should be adopted for the prevention of pregnancy. Individuals who have already suffered from an attack of

420

FORMS OF MENTAL DISEASE
life,

the disease should be compelled to lead a quiet

free
is

from

irritating influences.

The

susceptibility to alcohol

increased, hence its use should be most scrupulously avoided. In the treatment of the patient during the manic attacks,

the

first essential is

the removal of

all

forms of external

excitation.

Except in the mild cases, it is unsatisfactory to attempt to care for the patient at home, and even the milder forms run a more moderate course under the influence of a quiet and well-regulated hospital or sanitarium environment than at home. Unrestrained activity tends to

increase the excitement

therefore the pressure of activity should be limited as much as possible. One of the best
;

means
cases.

of accomplishing this
is

is

confinement in bed.

Bed

treatment

especially indicated in

anemic and debilitated

In severe excitement prolonged warm baths (see p. 140), used in connection with the bed treatment, give the most satisfactory results. The patients should alternate from
the bath to the bed
;

i.e.

when the excitement subsides

in the

bath, he can be returned to the bed until it reappears. It may be necessary in order to first introduce the patient to the bath to give a preliminary dose of hyoscin hydrobro-

mate (-^Q

to

-^ grain).

applied will often relieve renders medicinal treatment unnecessary. If the bath is not available, the use of hyoscin hydrobromate hypodermically, or

The prolonged warm bath properly the greatest excitement, and usually

by mouth,

is

the best remedy for subduing the

intense psychomotor activity. Scopolamin hydrobromate ("2To to -&fi grain) or paraldehyde may be substituted for the
hyoscin.

As the excitement permanently

subsides,

con-

finement in bed can be gradually relaxed and the patient given an opportunity to exercise in the open, fin very extreme excitement with impending collapse the adminis-

MANIC-DEPRESSIVE INSANITY
tration of whiskey of
in the case of

421

is necessary, and cardiac weakness, digitalis or coexisting caffein should be added.) The general management of the

brandy or camphor

patient is usually a very important adjuvant in controlling the excitement. This requires the greatest amount of tact

and patience on the part of the nurse; gentle friendliness at suitable moments sometimes renders what appears to be a most dangerous patient quite tractable. The nurse must exercise self-control, be free from all prejudice, avoid the use of discipline, and above all be frank and truthful. The nutrition of the patients demands special attention. An abundance of nutritious and easily digested food should
be given the patients at regular intervals. They should not be allowed to gulp their food, and hence it usually requires the constant attendance of the nurse at meal-time. Because of the great restlessness, it often requires consider-

able patience to get an excited patient to take sufficient nourishment. In severe cases the patients should be weighed frequently in order to ascertain if the body weight is falling
off, and, where necessary, artificial feeding by stomach or nasal tube can be employed.

It is very often a difficult matter to determine just when manic patients have recovered sufficiently to be discharged from treatment. Because of their great importunity and

impatience to be set free, there is a tendency to discharge them while some symptoms still remain. One of the dangers

premature release is the tendency to alcoholic indulgence, which regularly leads to a recurrence of the symptoms. The safest guide in deciding this question may be found in the body weight, which should have returned to normal. In the depressed states the patients should at once be
in

given the benefit of the rest treatment with confinement in

bed and ample feeding.

Except

in debilitated

and anemic

422

FORMS OF MENTAL DISEASE

cases, the patient should be permitted to leave the bed for a short period during the day to take exercise in the open. If this is not feasible, massage should be administered.

The

treatment taken in the open on a shielded but sunny porch should always be tried in preference to indoor confinement. If there is great agitation, opium in increasrest

ing doses (see p. 362)

is

often given with benefit.
controlled,
if

The insomnia should be

possible,

by the

aid of the variou^ physical measures, such as, hot baths at
night, hot liquid nourishment
etc.

and

upon retiring, gentle massage, Failing with these, one may employ on alternate days for short periods trional 15 grains, veronal 7J grains,

or paraldehyde 1 to 2 drachms. During prolonged periods of administration, these hypnotics should be varied.

The

nutrition also

demands

careful attention, for

which

purpose the patient should be frequently weighed. The food should be carefully selected and easily digestible. Abstinence from food often requires artificial feeding by nasal
or stomach tube.
exists, usually

The

relief of constipation,

which often

improves the appetite.

The patient must be relieved from all forms of excitation, and visits from relatives, long conversations, letter-writing, Rational conversation and encouretc., should be avoided. agement is helpful, except at the height of the disease, when
sometimes seems to be aggravating. In the lighter cases hypnotic suggestion has been used to great advantage in
it

relieving the insomnia, despondency,

and disagreeable somatic sensations. The greatest care must be exercised to prevent suicidal attempts, which are often to be most guarded
against at times when the patients, though still convalescing, believe themselves recovered, and also in the transition

periods between attacks.

X.

PARANOIA

1

PARANOIA
ment
of

is

a chronic progressive psychosis
life,

occurring

mostly in early adult

characterized by the gradual develop-

a

stable

progressive system of delusions,

without

marked mental

deterioration,

clouding of consciousness, or

disorder of thought, will, or conduct.

The disease is uncommon, constituting only Etiology. one to four per cent, of the cases admitted to insane hosMen are more often afflicted than women. The pitals.
disease begins

between the ages of twenty-five and forty. It on a defective constitutional basis, either condevelops
large percentage of the cases.
tricities

genital or acquired, defective heredity existing in a very

Peculiar traits

and eccen-

life, the patients being or seclusive. Some show perverted sexual moody, dreamy, instincts, or a marked aptitude for study or mental activity

may

be recognized early in

in special, limited fields.

Some have been abnormally bright

;

others have always been flighty, entering into many projects which they were unable to pursue successfully; many show

stigmata of degeneration. Exciting causes occasionally form the starting-point of the psychosis, such as an acute
illness,

excessive

mental

stress,

shock, business reverses,

deprivation, and disappointment.
Allgem. Zeitschr. f Psy., XXII, 368 Griesinger, Archiv. f Psy., I, 148; Sander, ibid., 387; Westphal, Allgem. Zeitschr. f. Psy., XXXIV, 252; Mercklin, Studien ttber primure Verriickheit, 1879; Amadie e
Snell,
.

1

.

;

Tonnini, Archivio italiano per

le

malattie nervose, 1884,
f.

1,

2; Werner,

Die Paranoia, 1891; Schule, Allgem. Zeitschr. Cramer, ibid., LI, 2 Sandberg, ibid., LII, 619.
;

Psy.,

L,

1

u.

2;

423

424

FORMS OF MENTAL DISEASE
is

There

as yet no demonstrable, pathological, anatomical

basis peculiar to paranoia.

Symptomatology.
is

The development

of

the psychosis
is

very gradual, extending sometimes over years, and

usually so insidious that the disease is in existence long before it is recognized. During this period it may have been noticed that the patient had changed in disposition,

having become somewhat

irritable,

grumbling, suspicious,

and that he had made indefinite physical complaints, especially of malaise and insomnia. The first symptom to be noticed is that the daily mental or manual labor becomes distasteful, and little affairs at home or in the shop cause displeasure and arouse suspicion. The wife seems less attentive, the children less loving, shopmates less friendly, and the overseer more stern. The and
easily discontented,

accidental absence of the morning greeting, or imaginary slight on the part of a close friend, sets the patient to think-

ing that
ful, is

it

cannot

all

be accidental.

He becomes

distrust-

constantly seeking other evidences of unfriendliness, and careful watching soon satisfies him that he is neglected,

both at home and at work.
accuses his friends of slights,
of plots.

He

make complaints, and members of his fraternity
begins to

leaves his employment, holds aloof from his companions and friends, and often becomes rude and discourteous. Some patients are able to ignore for a time the

He

apparent indifference of friends, but others become much disturbed and suspect a malicious purpose. They are morbidly sensitive, considering that such trifles as harmless jokes, smiles, or accidental nods of the head have special
reference to themselves.
intrigue, bill

Items in the paper indicate some

posters contain hints, some daily passer always lights his cigar or coughs when near them; men similarly dressed always meet them near the same corner, or are shad-

PARANOIA
owing their footsteps.
accidentally overheard.

425
as to an evident purdispelled

Any doubts

pose in all this are sooner or later

by remarks

In this way false interpretations

gradually assume greater prominence, and the resultant persecutory delusions are constantly increased and aggravated. Those who conscientiously approach and question friends or supposed intriguers are further alarmed and justified by the indifference displayed and the little satisfaction obtained; some ignore them, others answer evasively. Trivial matters which formerly passed unheeded are now falsely and absurdly interpreted and enter into the struc-

A spot on the coat, a calloused a decayed tooth, or a headache are all regarded as finger, positive proof of treachery and an effort to get them out
ture of their delusions.
of the

a slow process of poisoning. The appearance of natural baldness is readily explained by the application

way by

of electricity during sleep.
later, in connection with these delusions of which are firmly held and well moulded by a persecution, coherent train of reasoning, there may also appear expansive delusions. These may be coincident with the persecu-

Sooner or

tory ideas at the onset of the disease, but more frequently are the outcome of the delusions of persecution. The insistent persecution lead

creasing attention which the patients attract and the perthem to cast about for the reason.

While some find
still

this in property
it

which they

really possess,

others believe that

lies

in their personal charms, while

others conclude that they have been born for a special mission, or are of noble descent. thrifty Irish woman, who

A

had accumulated considerable property by dint
of her enemies to secure

of hardest

labor, finds a sufficient cause for her persecution in

attempts

her hard-earned accumulations.

A

factory employee already approaching the limits of the

426

FORMS OF MENTAL DISEASE

climacteric finds the reasons for her persecution in her

attractive appearance, and the desire of eminent men to seduce her. Where the expansive delusions are more directly evolved from the delusions of persecution, the patient asks himself why he is so molested and tormented, why so many,

not only individuals, but nations, seem directly interested in him, and why he is constantly accompanied by a secret Gradually it dawns upon him that he is a kidpatrol.

napped son
is

of a millionnaire or of a

of Napoleonic descent

crowned head, that he and lawful heir to the throne,

while his extensive landed properties are unlawfully used by the government. This explanation first appears in the

tendency to find evidences of persecution in

many

or

all

the events of their environment, and becomes prominent when the patients discover its purpose. Then all these

supposed facts assume a place in the chain of evidence which confirms their conclusions.

These delusions

may

only assume the form of an exag-

gerated feeling of self-importance. The patient considers himself especially renowned in his profession, a fine
lawyer, an excellent teacher,

an

interesting talker,

an

ideal

gentleman, a social favorite, or an individual worthy of great political distinction. Finally, a change of personality

may

result,

a direct descendant of Christ.
the

and the patient announces himself as titled, or The patients become aware
from

of this in various ways, one once receiving a salutation

President, another recognizing a striking similarity between himself and the equestrian statue of a famous

general.

Others are assured of their high station by the deference paid them by every one people bow to them, their
:

names are

in the paper, the orchestra begins to play as they enter the theatre, the prima donna directs her song at

them, and the birds chirp when they are near.

The appear-

PARANOIA

427

ance of the sun from under a cloud, casting its rays upon them, indicates that they are under the special guidance of

God.
All delusions, both persecutory and expansive, are held with great persistency, and built out into a coherent system, which
is

an

essential characteristic of the disease.

In the systematization of the delusions another prominent feature is the frequent appearance of retrospective
falsification

of

memory.

While
it

this

symptom

is

mostly

characteristic of paranoia,

may

also be present in the

paranoid forms of dementia prsecox and in melancholia. Here the patients, in reviewing their past life, find evidences
of persecution, or detect occurrences which at the time should

have indicated their superiority. The loss of a situation many years ago, derisive remarks by fellow-workmen, or

an by

injury,

now become
One

clear evidences of their persecution

patient recalled that when thirteen years of age a priest took from her a book, claiming that it was unfit for her to read. This incident she now regards as the be-

enemies.

ginning of years of persecution by the priesthood, who would seduce her and then hold her up as an example before the world. Another patient led his class in marching, and later

was chosen captain was
to have been a

of the boys' brigade:

these incidents

at that time should have

overhearing his

of the fact that he Another remembered parents whisper in an adjacent room, be-

made him aware

famous general.

coming mute at

his entrance,

and

later a disguised

woman,
which

who was
brother.

really his mother, visiting at the house,

all of

pointed to a noble birth and his displacement by a younger
similar incidents scattered throughout life are pointed out as striking evidences which aid in fortify-

Many

ing their system of delusions. An erotic element often appears in the delusions, which

428
in

FORMS OF MENTAL DISEASE

cases has been pronounced enough to lead to the recognition of an erotic paranoia. Likewise, the religious

some

coloring

is

sometimes strong enough to establish a religious

paranoia. In the erotic cases the patient usually believes himself the object of admiration by some lady who is attracted to him

and

solicits his attention.

She makes him aware of

this

by daily appearing at her window as he passes, or by casting Other evidence is gathered sly glances as she drives by. by anonymous love poems in daily papers. fantastic methods of communicating his love

Numerous
to her are

devised, to which she responds by wearing certain articles Their of clothing, or arranging her hair differently.

mutual admiration

He

hears

it

publicly regarded as an open secret. indirectly referred to everywhere, and friends
is

would have him infer, from casual remarks, that they are well pleased. Sometimes this fanciful, romantic, and even
platonic love is maintained for years without action; at others the patient makes an effort to approach his supposed
fiance* e.

Her

rebuffs

may

at

for the

accomplishment

of

be regarded as necessary Later she may her desires.
first

appear to him in the guise of one of his companions. Hallucinations are always present at some time, but do
not play a very important part in the psychosis, and rarely Hallucinapersist through the whole course of the disease.
tions of hearing are apt to be the

most prominent.

At

first

very indefinite noises

Later they hear their names mentioned, or derisive laughter from a crowd; nicknames are called out, some one curses below the window,

annoy them.

and bits of conversation from adjoining rooms excite them. The remarks are more often of a depreciatory nature. Hallucinations of sight are rare, but those of general sensibilthe hair is plucked at night, the ity are quite frequent,

PARANOIA
skin irritated
bullets,

429
flesh pierced

by poisonous powder, the

or the countenance transformed

by by the nightly

application of an iron mask.

There

is

never genuine insight into the disease.

The

patient, on the other hand, may complain

of all sorts of

physical ailments, such as nervousness, indigestion, pains in the head and back, for which he seeks medical attendance, but he cannot be made to realize the fallacy of his delusional ideas. The memory is well retained, and judg-

ment, except as biassed by the delusions, is unimpaired. The emotional attitude of the patients stands in direct
relation to the character of the delusions.

They

are

irri-

tated by their persecutors, are shy and excitable, and at first usually despondent; some, however, tolerate the persecution
fare.

and regard

it

as essential to their spiritual wel-

All

sooner or later become arrogant, proud, and

dogmatic.

In conduct the patients appear quite normal for a considerable time.
of their disease

Some

of them, long before the real nature

becomes evident, attract attention by their eccentricities, peculiarities in dress, oddities in manner, excessive religious zeal, or an attitude of self-importance. Later they become seclusive, move about in their employment from city to city, leave one shop to enter another,
where they soon detect the presence of their former perseIn this way an cutors, and are again compelled to leave.
iron

moulder travelled from San Francisco to Boston in

order to avoid the persecutions of his trade-union. change affords only temporary relief to the anxiety, as suspicious circumstances are soon noticed which leave no doubt that

A

news about them has been passed on from their last situation until finally their existence becomes known the world over. They become unstable in their behavior and mode of

430
living, are

FORMS OF MENTAL DISEASE

unable to conduct a successful business, and fail to support their families. In reaction to the delusions
they attempt to
call

public attention to their persecution

by writing newspaper articles and issuing pamphlets. Very often they apply to the police for protection. Frequently
into their

they assume the offensive, and take the matter of vengeance own hands. Not infrequently the first striking
one.

is a murderous assault upon some The paranoiac is for this reason the most dangerous of all insane. One patient assaulted the mayor of the city for keeping him from his fiancee; another drew a pistol upon a man with whom he was having an altercation over business matters, in the belief that he was the secret agent of the

evidence of the disease

French government sent to kill him. In accordance with expansive ideas the patient

may

address the President as his father, or demand access to a If millionnairess whose parents are keeping them apart.
confined in an institution, they may for a time ingeniously conceal their delusions until they find evidences of continued

persecution in their new surroundings, when the fellowpatients appear to them only as accomplices placed there
to aid in their discomfort.
is

Sometimes

their

confinement

regarded as an effort of their persecutors to

make them

insane.
tion,

patients submit gracefully to their detenconsidering it but another cross to bear before their

Some

final rescue

and the proclamation that they are

rightful

few patients even consider that they are being treated with the utmost consideration and the greatest
rulers.

A

attention, provided with the best quarters,

and granted

every possible privilege by those
injustice

who

recognize the great

done them.
of the disease

The course

always gradual, and

protracted. The onset is usually the disease has been in progis

PARANOIA
ress for

431

some time, even a few

years, before recognition.

When once established, the course is slowly progressive, with a gradual evolution of delusions which are constantly
being further systematized and made to encompass new environment. Several psychiatrists claim that the course
of the disease presents definite periods according to the stages of evolution of the delusions. At first there is the

prolonged period of insidious onset, by Regis called the
period of subjective analysis, followed by the persecutory period with the development of delusions of persecution with hallucinations, and finally the ambitious period acpatients usually are quite orderly, present an unclouded consciousness, and for many years are capable of considerable labor,
personality.

companied by a

change

of

The

both mental and manual.

After a duration of many years there appears a moderate degree of mental weakness. Patients become unable to apply themselves, take less notice of
their

environment and

less care of themselves.

In some

cases the disease may seem to be at a standstill for years, while in others partial remissions occur when the patients
for a time are able to rejoin their families,

but are rarely in

a condition to resume their accustomed occupations. The diagnosis depends upon the slow onset, the characteristic,

coherent, and systematized delusions of persecution with retrospective falsifications of memory, often associated with a change of personality, unclouded consciousness,

coherent
for

thought,

and absence
of

of

mental deterioration

many years.

dementia prcecox have already been differentiated from paranoia under the former disease.

The paranoid forms

few cases of dementia paralytica and melancholia may Dementia paralytica is to be distinsimulate paranoia.
guished by
its

A

rapid development, the early appearance of

432

FORMS OF MENTAL DISEASE
The conduct
of a

emotional weakness, and physical signs.
paranoiac
is

entirely dependent upon the content of the he cannot be reasoned with, is persistent in the delusions;

prosecution of his ideas, and is rarely submissive to confinement; while the paretic opposes his retention weakly

and with some stubbornness. The melancholiac presents a more rapid onset (three to nine months), a marked disturbance of the emotional attitude,
or intermittently
fear, self-accusations, occasional

clouding of consciousness,

an absence

of system in the formation of delusions, of the disease

dences of mental deterioration within the course of

and evitwo years.

^

The prognosis

is

very poor, as no case of

naturally limited to the removal of irritating influences and to confinement in an institution where systematic routine, with out-of-door life
is

genuine paranoia ever recovers. The treatment of the disease

and ample

exercise,

may

ameliorate or ward

off

the condi-

tion of mental weakness.

There are a few cases of paranoia which have been desig1 nated by Hitzig as querulent insanity (Querulantenwahn) which deserve a brief description here. The psychosis is
of gradual onset,
legal injustice,

and usually

arises as the result of

a defeat in court,

some an unjust award of

an unfair adjustment of claims, damages, in which the patient has been the sufferer. He refuses to carries the case from one court to another, and finally settle,
loss of property, or

develops an insatiable desire to fight to the bitter end. He reaches a point where he is unable to view the standpoint

any one else with any sense of justice, and his personal and desire completely obscure his better judgment. The statutes appear inadequate, and even the fundamental He sets aside principles of the law fail of comprehension.
of
belief
1

Hitzig,

XXVIII, 221

Ueber den Querulantenwahn, 1895 Koppen, Archiv Pfister, Allgem. Zeitschr. f. Psy., LIX, 589.
;

f.

Psy.,

;

PARANOIA
all

433

cany on the struggle, solicits symdenounces those who do not side with him. pathizers, and Hearsay and bits of knowledge gathered at random are cited
business in order to
as evidence in his behalf, and money is squandered in the pursuit of justice to the most extreme limits. He cannot

abide by the ultimate decision after all the usual means of justice have been exhausted. Failing to appreciate the needlessness of further struggle, he writes to magistrates,
legislators, consuls, ambassadors, and finally to the President or foreign rulers. Answers to these letters only create greater embitterment. His letters are long and carefully

particular kind of paper, times written with colored ink.
written, usually

upon a

and some-

and often becomes greatly excited in conversation, although at the same time priding himself upon his ability to exercise self-control.
is

The patient

irritable

Consciousness remains unclouded.
served;
in fact,
is
it

accuracy he

Memory is well preoften surprising to see with what able to quote from law books, to repeat
is

parts of speeches, and to enumerate various dates. Thought continues coherent, but there is a great tendency to monoto-

nous repetitions of the delusions. in even a short conversation.

One seldom misses them

There

is

no insight into the condition.

On

the other

hand, the patient is often encouraged in his belief by the fact that there are always many men, and not a few physicians,

who

will testify to his sanity.

cases of querulency are apt, after a prolonged to present greater deterioration than other varieties course,
of

The few

paranoia; the content of speech becomes more and more limited and somewhat incoherent, the irritability increases, the patient becoms peevish, indifferent, and some-

times even stupid.

XI.

EPILEPTIC INSANITY
is

EPILEPTIC insanity

a psychosis based upon epilepsy

which is characterized by a variable degree of mental impairment and by the recurrence of certain transitory mental states, designated epileptic ill-humor and epileptic befogged states.

The befogged
and
dipsomania.
Etiology.

states include pre-

stupor, anxious and conscious

and post-epileptic excitement deliria, and possibly also
most frequent
pre-

Defective heredity is the

disposing cause of epilepsy, appearing in eighty-seven per cent, of cases, while in over twenty-five per cent, epilepsy 1 found in 1070 cases exists in the parents. Spratling

hereditary

sixteen per cent, of which displayed parental epilepsy. He also found similar ratios in parental alcoholism and tubernearly
cent.,

taint in fifty-six per

notes among progenitors and relatives of the extreme frequency of migraine, headaches, epileptics
culosis.

Fere

2

infantile convulsions,
tion.

mental disturbances, and deteriora-

All authorities agree that parental alcoholism is a Wildermuth prolific source of epilepsy in the offspring.

considers
disorders,

its

influence almost as powerful as that of mental including epilepsy. Other factors in the pro-

genitors which predispose to epilepsy are insanity, syphilis, rheumatism, diabetes, and possibly chorea. Evidences of

congenital defect are frequently found in malformation or asymmetry of skull, microcephaly, hydrocephalus, the so" " called epileptic p'hysiognomy (broad forehead, broad and
1

Spratling, Epilepsy
Fe*re*,

and
434

its

Treatment, 1904.

2

Les Epilepsies, 1890.

EPILEPTIC INSANITY
flattened nose, prognathism, thick lips,

435

and

staring eyes

with wide pupils), feeble-mindedness, precocity, moral delinquency, and sexual perversion. Among the exciting or immediate causes of epilepsy we find cerebral palsies, dentition, emotional shocks (fright,
excitement, anxiety, grief),
tis,

many

acute infections, meningi-

thermic fever, overwork, gastro-intestinal disorders, disease of heart and kidneys, tobacco, lead, and other poisons,
carious teeth, foreign bodies in the intercourse.
ear,

and even sexual

brain lesions (especially hemorrhages), are frequently assigned as the cause of epiinjuries,
falls,

Head

such as blows,

and in a certain number of cases a direct relation between them can be traced. Wildermuth gives their as three and eight-tenths per cent., and Heeres frequency as four and two-tenths per cent. Spratling says that " trauma is more frequently the cause of epilepsy in men than in women (eight and five-tenths per cent, men three and five- tenths per cent, women)/' The numerous scars often found on the head are more frequently the results
lepsy,
:

than the causes of the malady. Akoholic excesses are by far the most important causes of

About ten epilepsy beginning after the twentieth year. per cent, of chronic alcoholics are thus afflicted. All epileptics present a marked intolerance to alcohol, and its use by them, even in small quantities, hastens the onset and intensifies the symptoms of mental disorder. Many imbeciles

and

idiots

and a few

seniles (thirty-four

hundredths

per cent.) develop epilepsy. Epilepsy is essentially a disease of youth, convulsions

appearing in thirty-four per cent, of cases in infancy. Spratling found in ten hundred and seventy cases twentysix and five- tenths per cent, develop under the age of five

436

FORMS OF MENTAL DISEASE

years; nineteen per cent, from five to nine years; twentyfour and four-tenths per cent, from ten to fourteen years;

and thirteen and
teen years,

six- tenths

per cent, from fifteen to ninefive-tenths per cent, found in fourteen hundred

a total of

fifty-six

and

under twenty years.

Gowers

fifty cases that in seventy-four and eight-tenths per cent, the onset occurred before the twentieth year.

and

As not all epileptics are insane, it is evident Pathology. that the pathology of epileptic insanity must be based upon
that of the seizures plus hereditary taint, constitutional defect, and other factors whose nature and influence are

not yet thoroughly known. There is a wide variation in views as to the nature of epilepsy, but it is now generally
regarded as a cortical disease which is general and profound. Gross lesions are of secondary importance and mostly act as contributing factors. Among the most important gross

changes revealed by autopsy are alterations in the texture and shape of the skull, old lesions of infantile cerebral
hemiplegia (four to ten per cent.), sclerosis of the cornu

ammonis, porencephaly, encephalic scars, neoplasms, etc. Wildermuth asserts that thirteen and three-tenths per cent, of his cases were due to polioencephalitis, and five and
eight-tenths per
called
cent, to other

maining eighty-three and
" "

In the regross lesions. nine-tenths per cent, of his cases

various anaidiopathic epilepsy tomical changes were found in the brain, which probably bore some relation to the clinical symptoms. The micro-

genuine

or

scopic changes thus far found are cortical gliosis merous cortical cell changes, such as chromatolysis;
late epilepsy
litic

and nuwhile in

we

find arteriosclerosis

lesions.

It is possible

and occasionally syphiand very probable that many

of the lesions

found in the brain are the results of epilepsy

and not the

causes.

EPILEPTIC INSANITY

437

periodicity of the seizures may possibly be explained the apparent tendency in the nervous system to a periodiby If the researches of cal reaction to any continued irritation.

The

it

Krainsky, Cabitto, Agostini, and others can be corroborated, would seem probable that idiopathic epilepsy is due to a

toxic condition arising from faulty metabolism, and that the immediate cause of the convulsions is the accumulation of
deleterious substances in the blood or a faulty chemotaxis This theory receives further weight
fact that the convulsions are frequently

of the cortical cells.

accomwhich point to intoxication, as drowsipanied by symptoms ness, headache, nausea, etc.; and also from the fact that

from the

epileptiform attacks occur in
intoxication,

many

conditions of chronic

especially

from

alcohol,
cell

"

From

the nature of the cortical

and uremia. changes we have a
lead,

right to expect that the inciting agents will be very active * nuclear poisons." It is now believed that the blood, sweat, urine, and gastric contents are hypertoxic for some time before, during,

and

after the seizures,

and hypotoxic

in the intervallary

periods, but no definite conclusion as to the sources of this alteration in toxicity has been reached. Epilepsy due to

circumscribed lesions, traumatic or otherwise, of the brain,

can hardly be ascribed to toxicity alone. Even if we should base the known cerebral changes upon a chronic intoxication, we would still need to explain the periodicity of the
accumulation of toxins, and also the hereditary relationship of epilepsy to other mental and nervous diseases. On the whole, it seems probable that the ultimate
attacks, the

and

characteristic cause of the symptom-complex epilepsy is to be found in morbid conditions of the nervous tissues , especially the cortical cells,
1

most

likely

due
its

to

chemical changes.

Spratling,

Epilepsy and

Treatment.

438

FORMS OF MENTAL DISEASE
Epilepsy

Symptomatology.
per cent, this

unquestionably

produces

some mental deterioration
is slight,

in every case, but in about fifty

chiefly affecting the

most

striking feature of the epileptic

memory. The weakmindedness is

the slow evolution of psychic processes, external stimuli arousing only a meagre response in consciousness. In the

majority of cases of epileptic insanity the degree of deterioration once established may remain without marked progress

In a few cases, however, a condition of profound deterioration may be reached. Hallucinations are exceedingly infrequent except in the
for years or even
life.

befogged states and anxious and conscious deliria. When present in the interparoxysmal periods, they generally have

a religious character.

Illusions are quite frequent for a short period before and after attacks of grand mal. Consciousness is usually clear and orientation normal in the intervallary periods, except during the befogged states.

Apprehension of the daily routine
tion
is

is fairly

keen, but atten-

always somewhat impaired or
is

easily fatigued.

Memory

always impaired, sometimes to a great extent.

While prominent events and the ordinary daily routine may be recalled, the recollection of the general course of life, whether remote or recent, is more or less hazy. In contrast
to the

memory

defects found in other deterioration psy-

choses, patients are able to express clearly
their remaining

and coherently

narrow

circles of

thought.

shows a marked atrophy of the store In of ideas with scanty assimilation of new impressions. conversation and writing there is a strong tendency to detail
train of thought

The

and

circumstantiality. Their narratives are obscured by a multitude of data and irrelevant or unessential accessories

which greatly impede the progress toward and development
of the goal ideas.

The connection

is

not

lost,

however, and

EPILEPTIC INSANITY
the goal
is

439

thought is ing a large part of their time in reading the Bible or in praying aloud. Patients adhere to familiar paths, and their
vocabulary consists largely of set phrases, platitudes, Bible The narrowness of thought naturally texts, proverbs, etc.
leads to a greater prominence of the ego. This is especially noticeable in the conversation of epileptics, in which they

ultimately reached. The religious content of another striking symptom, many patients spend-

indulge in praise of self and family, and pay to personal matters.

much
if

attention

The imagination is practically abolished, and epileptics show no

inactive,

not entirely

ability to reconstruct or

recombine the materials furnished by old experiences or new perceptions. They occasionally, however, write verse which

shows an unruly and riotous fancy, as in the following:

"E
F

is is

the eel

the finch

who soars to the sky; who is fond of pie."

Judgment invariably becomes impaired as mental deterioration progresses, but delusions are not common except in some of the transitory epileptic mental states, when they are
accompanied by hallucinations.
hypochondriacal. "

Many

epileptics
is

become

The

true relation of ideas
sense," tact,

obscured or

even

lost,

and

common

and

discretion are

seldom displayed. Patients never adequately recognize the incongruity between their plans and their limited ability.

One man with marked mental and physical defects, whose schooling had been meagre, gravely proposed to study theology; and another who could hardly name the simplest flowers desired to become a florist. As a rule, however, epileptics Imve some insight into their condition, realizing that they have convulsions, poor memory, and difficulty of
thought.

Among

the most marked

symptoms

are those occurring in

440
the emotional

FORMS OF MENTAL DISEASE
even when mental deterioration is not There is almost always an increased irritability
field,

advanced.

manifested by their peevishness, obstinacy, unruliness, also by frequent outbreaks of emotional excitement as well as

sudden alternations from elation to depression, and the
reverse.

particularly apt to occur in the proximity of the convulsions and is easily aroused by alcohol. Some " of an internal anguish," or fear. They patients complain are easily angered, are threatening, quarrelsome, violent, and

This

is

dangerous. Usually the finer feelings become blunted, and there often exists a uniform state of apathy. On the other

hand there are a few patients who
bility.

for years always display
irrita-

a placid, amiable disposition, free from evidences of

tic

Morbid and sudden impulses are frequent and characterissymptoms of epileptic insanity. These are largely due

to increased irritability or lack of self-control. Patients will attack any one who disturbs them, and often in a blind rage

suddenly
cent

inflict

severe

and dangerous

injuries,

even on inno-

any provocation. These impulses are by no means confined to the pre- or post-paroxysmal stages, as many suppose, but may arise at long intervals between the seizures. The wild state of blind
where patients run amuck, striking and assaulting the characteristic indiscriminately every one in their range, is a nerve storm which may justly be conepileptic furor, " sidered as an equivalent." These sudden impulses to violence and even homicide render epileptics especially danrage,

and

inoffensive bystanders, without

gerous.

are very infrequent, and their more so. accomplishment The conduct, apart from the stubbornness and morbid imSuicidal impulses
still

pulses above described, is usually good. Epileptics as a rule are neat, orderly, and observe the usual convention-

EPILEPTIC INSANITY
alities unless deterioration is

441

quite marked.

Some

patients

display marked sexual excitement, and some are inveterate masturbators. All epileptics show a diminished capacity
for work, especially

where the higher grades of mental and

physical training are requisite. They may engage with fair success in simple routine occupations where little or no
initiative is required,

but unless carefully directed and super-

vised, are apt to slight their

Physical Symptoms. toms in epileptic insanity are the convulsions, which may assume the type of grand or petit mal. In the former there may be an aura, followed by a cry, a fall, and tonic followed
first, but rapidly over the entire body. During the convulsions, extending which may last from two to ten minutes, consciousness is totally abolished, but returns gradually within a period of a

work or leave it unfinished. The most important physical symp-

by

clonic convulsions, usually localized at

few minutes up to several hours. In status epilepticus there may be from twenty to even several hundred attacks of grand mal, without a return to consciousness in the intervals.

In petit mal there is a very brief loss of consciousness (usually only one or two seconds), either without any con-

vulsive

movements

or with very slight ones which often

elude observation.

The reflexes are abolished during the convulsions, and in some cases are not restored for one or more hours. In 1088
observations on male epileptics, Keniston
1

found that the

normal plantar reflex (flexion of toes, etc.) was present in both feet immediately after clonus had ceased in forty-five, and one hour later in two hundred twenty-six, cases; the
Babinski phenomenon (extension of toes with dorsiflexion of ankle) occurred in one hundred three cases directly after
the seizure, and in one hundred twelve cases one hour later. Keniston, Journ. of Amer. Med. Assoc., March 21, 1903.
1

442

FORMS OF MENTAL DISEASE

An extensor response was found in right or left foot in ninetynine and fifty-three cases, respectively, and a flexor response in right or left foot in ninety-nine and two hundred eleven
cases, respectively, while

a mixed response, that

is,

extension

in foot

and

flexion in the other, occurred in eighty-two cases

directly after a seizure

one hour

later.

and in one hundred forty-seven cases The plantar reflex was abolished in six hun-

dred sixty cases immediately after the convulsions, and in three hundred thirty-nine cases one hour later. The kneejerks were active in three hundred ninety-six cases,

moderate in one hundred thirty-seven, and absent in hundred thirty-nine cases.

five

The

speech of epileptics

is

often altered

and very char-

acteristic.

It is abrupt, with intervals after each phrase, often drawling, jerky, or strongly accented. During excitement it may be so rapid as to be indistinguishable, were

it

not for the fact that a few phrases are repeated over and over again. Tuberculosis and organic and functional diseases of the heart are quite frequent, and the pulse rate is often increased. Epileptics rarely complain of headache,

and often show an
gesia,

insensibility to pain

amounting to anal-

while their frequent wounds usually heal rapidly. Richter found anaesthetic areas in forty per cent, of his
cases, general analgesia in

and hemihypaesthesia
Paraesthesias

in

twelve and two-tenths per cent., ten and two-tenths per cent.

are very common. Sleep is often irregular and muscular strength diminished. Appetite is usually good, and most epileptics are greedy and gluttonous. As
residuals of seizures

we

find scars of all kinds, especially

on the head, broken noses, extensive burns, and absence of front teeth; and as causal residuals we see evidences of
alcoholic abuses, sequellse of early brain diseases, or arteriosclerotic alterations, and cranial scars.
syphilitic

We

occa-

EPILEPTIC INSANITY

443

sionally find after seizures small cutaneous hemorrhages, particularly in the conjunctiva.

In addition to the above general mental and physical symptoms which constitute the epileptic dementia, there
occur with more or less regularity certain transitory epileptic mental states, which occur periodically and independently of
external causes.

The most important

of these states

is

the periodical

ill-

humor, which according to Aschaffenburg occurs in 78 per cent, of epileptics and is characterized by a marked emotional

much involvement of consciousness. The separate attacks bear an extraordinary resemblance to each other. The same complaints, the same delusions, and the same impulses recur. The phraseology of the patients is definite, the behavior characteristic, and the expression similar. These attacks vary in intensity, and often come on in the morning. Sometimes the intervals are so
tension without

regular that the time of recurrence can be foretold with Patients usually awake peevish, irritolerable accuracy. often table, fault-finding, threatening, and quarrelsome;

commit sudden and unprovoked

assaults

on the nearest per-

son; break glass or destroy bedding and furniture, and use profane or obscene language. Very often the emotional

one of anxiety, when the patients complain of feeling homesick, and low spirited, and of being troubled with sad thoughts, have presentiments, and express delusions
condition
is

of self-accusation.

Occasionally hallucinations also appear.
of feelings of

At the same time the patients may complain

numbness, pressure in the head, ringing in the ears, and difficulty of thought. They are unable to work, wander about, sometimes remain in bed, and frequently attempt
suicide.

Less often the patients develop a state of expan-

siveness or ecstasy.

They then run about with

glaring eyes

444

FORMS OF MENTAL DISEASE

and happy countenances. They shout, throw things about, and get into all kinds of trouble, tease their mates, pray loudly, and express expansive religious ideas. Occasionally
there is a flight of ideas. Furthermore there is great emotional Some patients irritability with a tendency to aggressiveness.
rapidly develop a condition of marked excitement. Sometimes the patients develop a delusional state with emotional
irritability

and anxiety and also occasionally accompanied by hallucinations, which condition might be termed a

paranoid condition. While the ill-humor usually occurs after a seizure, it may precede it, in which case the convulsion generally clears the

mental atmosphere. The attacks rarely last more than a few hours, but may persist for a week or more. Abatement is gradual, and is often followed by a feeling of complacency
or well-being. In some cases the hallucinations and delusions may persist with little change for weeks or months,

simulating closely
praecox,

certain conditions

found in dementia

but

finally the

hallucinations

and delusions en-

tirely disappear.

Befogged states represent the second large group of transitory epileptic states, and are characterized by a more or less
profound clouding of consciousness.
pre- and
post-epileptic insanity,

These states include
,

psychic epilepsy

epileptic
of

stupor, anxious delirium, conscious delirium,

some cases

somnambulism, and possibly dipsomania. The befogged states are sometimes preceded by the transitory states of ill-humor Alcohol may predispose to them, even when just described. taken in very moderate quantities. Here all sorts of morbid sensory Pre-epileptic Insanity.
impressions
vision,

may

arise,

flashes of light,

impairment of

indefinite

parsesthesias,

or strange sounds, peculiar odors, and which are not to be confounded with the

EPILEPTIC INSANITY
individual aura,
ideas,
falsified

445

when such

exists.

identifications,

There may be fixed monotonous repetitions of

words or phrases, involuntary or grotesque movements, and imperative impulses, as to strike, destroy furniture, or sometimes a few minutes or even In a short time kill. consciousness becomes clouded, and the conseconds vulsion begins. In a few cases the latter passes over into
a pronounced dreaminess lasting for hours or days.
Post-epileptic Insanity.
It is

more common and

is

char-

by deep dazedness after the seizure, lasting for hours or even days. Patients do not understand questions,
acterized

speak confusedly (paraphasia), are completely disoriented,

wander aimlessly about,

collect all obtainable objects,

and

even drink their urine. While active sensory disturbances are undoubtedly present, no account can be obtained from the patients, who have complete amnesia of all that has

happened. As a rule, they recover their normal mental and emotional attitude very gradually. Mental and emotional disturbances Psychic Epilepsy.
very similar to the above

appear in the intervallary of the convulsions, and are periods, entirely independent

may

then called
ditions are

equivalents," or psychic epilepsy. These conby no means rare,, and are frequently observed

"

in hospitals.

They

are

more

liable to occur in patients

who

have seizures at long

intervals.

The

essential feature of

psychic epilepsy is the disturbance of consciousness. Patients are confused, move and act in a mechanical or automatic

manner, and often present evidences of
tions,

illusions, hallucina-

and

delusions.

They wander

aimlessly about,

and do

not appear to recognize any one, but will sometimes reply
incoherently to questions. Occasionally they assume fixed or peculiar positions, or gaze steadily at one point. In some
instances they display a heightened excitement,

and again

446

FORMS OF MENTAL DISEASE

a gloomy stupor, during which they may masturbate, expose their person, or attempt sexual assaults. Patients

have been known to set
such

fire

to their bedding or furniture for

The n